Modifier 25: Significant, Separately Identifiable Evaluation and Management Service

Definition

Modifier 25 is used when a significant, separately identifiable evaluation and management (E/M) service is provided on the same day as a procedure. The E/M service must have independent clinical significance and address a condition distinct from the procedure itself. Add modifier 25 to the E/M code to indicate the service warrants separate payment.

When to Use

Patient comes in for routine preventive exam (99213) and acute problem identified requiring treatment (e.g., cerumen removal 69210)
Established patient visit (99214) for diabetic management, then foot care procedure (11721 removal of warts)
New patient comprehensive visit (99203) and minor surgical procedure same day (e.g., skin biopsy 11100)
Pre-operative clearance E/M (99213) and minor procedure unrelated to surgery (e.g., vaccination 90658)

Documentation Requirements

Document distinct medical necessity in the chart. Show the E/M service evaluation in separate note section from procedure. If E/M is preventive and procedure is problem-focused, clearly separate the two. Include reason for visit, history of present illness, and examination findings. Time spent on E/M and procedure should be documented separately if billing higher-level codes.

Payer-Specific Rules

Payer	Acceptance	Common Denials	Notes
Medicare	Accepted when documented separately	CO-59: Service/item not eligible for payment	Deny if E/M documented as incidental. Require distinct documentation.
Aetna	Accepted with modifier 25	CO-8: Services not covered	May bundle if E/M is preventive and procedure is incidental to care.
United Healthcare	Accepted when clinically distinct	CO-4: Service/item billed during global period	Strict on documentation. E/M must show separate clinical decision-making.
Cigna	Accepted with proper documentation	CO-59: Service/item not separately payable	Bundle if E/M only addresses procedure post-op care.
Humana	Accepted when medically necessary	CO-8: Services denied based on plan	Deny if only preventive E/M, procedure unrelated to complaint.

Related Modifiers

59 – Use when modifier 25 is insufficient; bundle edit exists between codes.
XE – Separate encounter same day. Use when E/M from different encounter session.
26 – Professional component. Use when billing E/M with split-billing service.

Common Denials

CARC Code	Reason	Primary Cause
CO-59	Service/item not separately payable	No separate documentation for E/M service; insurer sees E/M as incidental to procedure.
CO-4	Service bundled in global period	Modifier 25 applied but procedure has pre-operative E/M included in global package.
CO-151	Claim submitted without required supporting documentation	Insufficient documentation proving E/M was distinct from procedure.

FAQ

Can I use modifier 25 with telehealth E/M?

Yes. If E/M is provided via telehealth (modifier 95) on same day as procedure, use both modifiers: 99213-25-95.

Does modifier 25 work with preventive care codes?

Yes, if you also provide problem-focused service. Document both separately. If only preventive service, do not use modifier 25.

What if the E/M and procedure are for the same condition?

Modifier 25 does not apply if E/M is pre-operative evaluation for the procedure. Use modifier 25 only when E/M is unrelated or only partially related.

Prevent These Denials

Reduce modifier 25 denials. Get a co-pilot to review your E/M documentation and bundle edit rules.

Related Resources

This reference is current as of 2026-03-23. Payer policies change. Always verify against the payer's latest policy documentation.

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