Billing modifier · CMS NCCI policy
Modifier 25: a separate E/M visit on procedure day.
Modifier 25 goes on an evaluation and management code when the E/M service was significant and separately identifiable from another service the same day. It is not a way to get a second payment for the routine work already inside a procedure.
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The definition CMS uses
Significant, Separately Identifiable Evaluation and Management Service by the Same Physician or Other Qualified Health Care Professional on the Same Day of the Procedure or Other Service.
That is the CPT descriptor as quoted in the Medicare NCCI Policy Manual, Chapter 1 (revision date 1/1/2026). CMS says modifier 25 may be appended to an E/M code to show the visit is significant and separately identifiable from other services reported the same day, and that the E/M may relate to the same or a different diagnosis as the procedure.
The rule that causes most denials
CMS says modifier 25 may be appended to E/M services reported with minor surgical procedures (global periods of 000 or 010 days) or procedures not covered by the global surgery rules (global indicator XXX). Because those procedures include pre-, intra- and post-procedure work, the provider should not report an E/M for that work. CMS adds that Medicare's global surgery rules prevent a separate E/M for the work of deciding to perform a minor surgical procedure, whether the patient is new or established.
Worked example (hypothetical)
A patient comes in for a sore throat and, during the same visit, also asks about a mole that needs a minor procedure. The throat evaluation is a significant, separate problem and is documented as such, so the E/M is billed with 25. If the only reason for the visit was to look at the mole and decide to remove it, the decision to operate is part of the procedure, so a 25 E/M would not be supported.
What the payer will check
- That the E/M and the procedure both appear on the same date and provider.
- That documentation shows work beyond the usual pre-procedure assessment.
- That the procedure has a global period of 000 or 010 days or an XXX indicator, as CMS describes.
If the modifier is missing, expect CARC 97, bundled into the procedure. If the modifier is on a code it does not fit, expect CARC 4.
Scope and limits
CPT descriptors are published by the American Medical Association. This page quotes the short descriptor as it appears in CMS's public manual and does not reproduce the CPT book. Commercial payers can add their own rules for 25, such as reduced payment for the E/M. Check each payer.
Sources
- CMS: Medicare NCCI Policy Manual, Chapter 1 (rev. 1/1/2026) — section on modifiers 22, 25, 58, 59 (retrieved 2026-11-01)
- CMS: Medicare NCCI Policy Manual page — manual index, page modified 01/06/2026
- X12: Claim Adjustment Reason Codes — code text, start and last-modified dates (list dated 10/30/2026, retrieved 2026-11-01)
Every code description and rule above was retrieved from these pages on November 1, 2026. Payers revise code lists, contracts and policies, so confirm anything that affects a claim or a deadline with the payer.
Frequently asked questions
Does modifier 25 go on the procedure or the E/M?
On the E/M code. CMS describes it as appended to an evaluation and management CPT code.
Can the E/M and the procedure share a diagnosis?
Yes. CMS says the E/M service may be related to the same or a different diagnosis as the procedure.
Does modifier 25 guarantee payment?
No. It tells the payer the E/M was separate. The documentation still has to show it, and payers apply their own edits.
Not legal, billing or medical advice
This page explains published code lists and rules and runs a lookup in your browser. It cannot see your claim, your contract or any payer's policy. Confirm with the payer or your Medicare Administrative Contractor before you resubmit, appeal or bill a patient.