Modifier 25: When to Use It and How It Affects Payment
Modifier 25 marks a significant, separately identifiable E/M visit on a procedure day. Medicare's rules, when 57 or 59 fits instead, and the classic denial.
Modifier 25 is a billing modifier added to an evaluation and management (E/M) code to show that, on the same day as a procedure or other service, the same practitioner also provided a significant visit that stands on its own. Without it, Medicare treats the visit as part of the procedure and doesn't pay it separately.
Key takeaways
- 25 goes on the E/M code only, never on the procedure.
- The visit must go beyond the routine check before a procedure. Deciding to do a minor procedure is already paid inside that procedure.
- A different diagnosis isn't required, but the note has to show separate work.
- A visit the day before or the day of a 90-day major surgery that led to the decision to operate takes 57, not 25.
- 25 doesn't change the rate. The E/M and the procedure each pay their normal fee schedule amount.
Modifier 25 · payment effect
With and without the modifier
99214 without 25 · national office
$135.61
Office visit
99214-25 · No change to the rate
$135.61
Tells Medicare the E/M is separate from a same-day procedure. The E/M is paid at its own rate; the modifier doesn’t raise or lower it.
What modifier 25 means
Every procedure with a global period includes some evaluation: checking the patient is fit for it, explaining it, getting consent. Medicare's global surgery rules fold that work into the procedure's payment. Modifier 25 is how you tell the payer that this visit was more than that: a separate problem was evaluated, or the procedure's own problem needed substantially more work than the usual pre-procedure assessment.
CMS says modifier 25 should be used only on E/M services, only when the same physician or qualified nonphysician practitioner sees the same patient on the same day as another procedure or service, and only for "a significant, separately identifiable E/M service that is above and beyond the usual pre- and post-operative work of the procedure" (Claims Processing Manual, Pub. 100-04, ch. 12, §30.6.6.B).
When to use modifier 25
- A separate problem on a procedure day. A patient comes in for a scheduled knee injection (20610) and you also assess and adjust treatment for uncontrolled diabetes. Bill the injection, plus 99214-25 for the diabetes work.
- A new problem that ends in a minor procedure, with real evaluation. A head-injury patient gets a full neurological exam before you close a scalp laceration. CMS uses this exact example: the visit is billable because the exam went far beyond confirming the need for sutures.
- An E/M with another separately billed service, such as a problem-oriented visit on the same day as a preventive visit or a diagnostic test the practitioner performs.
Document the E/M so it stands alone: the history, exam and decision making for the separate problem, kept distinct from the procedure note.
Decide
Was a procedure or other separately billed service done the same day by the same practitioner?
When not to use modifier 25
Also don't use 25:
- On the procedure code. It belongs on the E/M line.
- For the decision to perform major surgery. A visit the day before or the day of a 90-day procedure that results in the decision to operate takes modifier 57.
- To bill two E/M visits by the same practitioner on one day. CMS says MACs may not let 25 generate payment for multiple E/M services the same day.
- On a non-E/M service. Separate procedures use 59 or an X modifier.
- For an unrelated visit during a postoperative period. That's modifier 24.
How modifier 25 affects payment
Modifier 25 has no payment adjustment. The E/M is paid at its full fee schedule amount, and the procedure is paid as it normally would be. E/M codes aren't subject to the multiple procedure reduction, so the visit isn't cut by being billed alongside surgery.
Without 25, the visit is denied as included in the procedure's global package. CMS doesn't require documentation with the claim, but the record must support both services, and MACs that find a pattern of misuse can impose prepayment screens.
Modifier 25 vs 57, 24 and 59
| Modifier | Goes on | Use it when |
|---|---|---|
| 25 | E/M | Separate, significant visit on the same day as a procedure or other service |
| 57 | E/M | Visit that led to the decision for a 90-day surgery, day of or day before |
| 24 | E/M | Unrelated visit during another procedure's postoperative period |
| 59 | Procedure | Two procedures that normally bundle were separate and distinct |
The longer comparison, with examples, is in modifier 25 vs 59.
FAQ
What is modifier 25 used for?
To get a same-day E/M visit paid alongside a procedure or other service, when the visit was significant and separately identifiable from the procedure's usual pre- and post-procedure work.
When to use 25 and 59 modifiers?
25 goes on an E/M visit that was separate from a same-day procedure. 59 goes on a procedure that was separate from another procedure. They don't substitute for each other, and 59 should never be put on an E/M code.
What is modifier 24 and 25?
Both go on E/M codes. 25 is for a separate visit on the same day as a procedure. 24 is for an unrelated visit on a later day that falls inside the postoperative period of a surgery the same practitioner performed.
Can you use modifier 25 with 99214?
Yes. 99214, like any office or outpatient E/M code, can carry 25 when the visit meets the "significant, separately identifiable" bar on a procedure day. The level is chosen from the separate work only, not the procedure.
Keep reading
- Modifier 25 vs 59: the visit modifier against the procedure modifier.
- Modifier 57 and modifier 24 for the other global surgery visit modifiers.
- Global period calculator to see which days a procedure's package covers.
- Codes on this page: 99214 99213 20610
Sources: Medicare Claims Processing Manual, Pub. 100-04, ch. 12, §30.6.6.B, §40.1.C and §40.2.A.4 and A.8; CMS MLN1783722 (April 2026). Verified October 6, 2026.
