Significant, Separately Identifiable E/M Service

Signals a significant, separately identifiable E/M service by the same provider on the same day as another procedure or service.

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CPT modifier 25 indicates that on the same day as another procedure or service, the same physician or other qualified health care professional provided a significant, separately identifiable evaluation and management (E/M) service that is distinct from the usual preoperative or postoperative care bundled into the procedure. Per the AMA/CPT guidance, modifier 25 should be appended only to an E/M code when documentation demonstrates that the E/M visit was above and beyond the typical work associated with the procedure, could stand alone as a billable E/M, and includes sufficient medical decision-making or time to justify separate reporting. The modifier must not be used when the E/M resulted solely in the decision to perform surgery (modifier 57 applies) or when the E/M is part of the procedure with no additional distinct work provided.(ama-assn.org)

Appropriate use of modifier 25 can allow separate payment for the E/M service even when performed on the same day as another procedure, but reimbursement varies by payer. Medicare generally allows payment when modifier 25 is used correctly, while private payers may require extra documentation, reduce payment, or deny the claim. Claims with modifier 25 often receive increased scrutiny; certain clinical scenarios (for example, E/M services billed with intravitreal injections) have been the subject of reviews.(ama-assn.org; cms.gov)

Practical examples that illustrate modifier 25 usage include: a lesion removal visit where the provider performs a significant problem-oriented evaluation or counseling beyond the normal pre-procedure assessment (e.g., 99213-25 plus 11100), and a preventive medicine visit where a new acute problem is evaluated and treated during the same encounter (e.g., 99395 plus 99212-25). Keep in mind payer variability—some Medicaid or private plans may prohibit billing an E/M on the same date as a procedure despite CPT guidance—and denials can sometimes be overturned by appealing with AMA/CPT language and supporting documentation.(aafp.org; aapc.com; ama-assn.org)

Significant, Separately Identifiable E/M Service

Signals a significant, separately identifiable E/M service by the same provider on the same day as another procedure or service.

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Get alerted when payer policies referencing 25 are released or updated.

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When to Use

When to apply: Use modifier 25 only on an E/M code to indicate the same provider delivered a significant, separately identifiable E/M service on the same day as another procedure or service — i.e., work that is above and beyond the usual pre‑ or postoperative care and could stand alone as a billable E/M.
Common exclusions/misuse to avoid: Do not append modifier 25 when the E/M merely documents the decision to perform a procedure (that scenario uses modifier 57), or when the E/M is routine, bundled pre/post‑procedure care with no additional distinct work. Never apply 25 to non‑E/M codes.
Documentation payers typically expect: Clear records showing the E/M was significant and separately identifiable from the procedure — sufficient medical decision‑making or total time to support the E/M code, separate problem‑focused history/exam or counseling beyond usual procedure preparation, and explicit notes that justify billing the E/M as standalone.
Payer variability and scrutiny: Expect heightened review; Medicare generally pays appropriately when 25 is justified, but private payers and some Medicaid plans vary widely and may deny or reduce payment — be prepared to supply supporting documentation and appeal using AMA/CPT guidance.
Use examples only as guidance: Typical acceptable scenarios include a preventive visit with an unrelated acute problem requiring separate E/M care, or a procedure visit where substantial additional evaluation/counseling/problem management occurred and is documented as distinct from the procedure work.

Clinical Scenarios

Lesion removal with separate counseling: A patient presents for removal of a skin lesion (procedure). During the same visit the provider performs a significant, separately identifiable E/M visit — documents an extended problem‑focused history and exam, discusses possible malignancy, outlines additional diagnostic planning, and records distinct medical decision‑making beyond routine pre/postoperative care. The E/M code would be reported with modifier ‑25 alongside the procedure code (e.g., E/M code‑25 and the lesion removal code) to show the E/M was above and beyond the bundled procedure work.
Preventive visit plus new acute problem: A patient comes for a preventive/well visit and during the encounter reports new ear pain and fever. The clinician separately evaluates the acute complaint, documents a problem‑focused exam and medical decision‑making that could stand alone, and initiates treatment. The preventive medicine code is reported for the well visit and the separate problem‑focused E/M is reported with modifier ‑25 to indicate a significant, separately identifiable E/M service on the same day.
Procedure visit with additional unrelated E/M: A patient receives a minor office procedure (for example, an injection or minor wound care). In the same encounter the provider addresses an unrelated new complaint that requires an independent evaluation and management service (documented history, exam, and decision‑making beyond the procedure), and bills the E/M with modifier ‑25 in addition to the procedure code to reflect the distinct, billable E/M service.

References

Code	Name
22	Increased Procedural Services
23	Unusual Anesthesia Requirement
24	Unrelated Postoperative E/M Service
26	Professional Component Billing
27	Separate Same‑Day Outpatient E/M
32	Mandated Third-Party Services
33	Preventive Service (ACA)
47	Anesthesia Provided by Surgeon
50	Bilateral Procedure Billing
51	Multiple Procedures (Modifier -51)
52	Reduced Services (Provider Discretion)
53	Discontinued Procedure (Provider)
54	Surgical Care Only
55	Postoperative Management Only
56	Preoperative Management Only
57	Decision for Surgery
58	staged or related postop procedure
59	Distinct Procedural Service
62	Two Surgeons/Co‑Surgeons
63	Procedure on infant ≤ 4 kg

1.CPT® Codes and Descriptions. AAPC. Retrieved Aug 11, 2026.Maintains the CPT code set's official descriptions and guidelines, licensed from the American Medical Association, used as the definitional source for CPT codes on this page.
2.HCPCS Quarterly Update. Centers for Medicare & Medicaid Services (CMS). Retrieved Aug 11, 2026.CMS's quarterly release of HCPCS Level II codes and short/long descriptors, the source for HCPCS code definitions and update history.
3.ICD-10-CM Full Code List. Centers for Medicare & Medicaid Services (CMS). Retrieved Aug 11, 2026.CMS's complete ICD-10-CM diagnosis code list, used to cross-reference diagnosis codes associated with this procedure or service.

When to Use

When to apply: Use modifier 25 only on an E/M code to indicate the same provider delivered a significant, separately identifiable E/M service on the same day as another procedure or service — i.e., work that is above and beyond the usual pre‑ or postoperative care and could stand alone as a billable E/M.
Common exclusions/misuse to avoid: Do not append modifier 25 when the E/M merely documents the decision to perform a procedure (that scenario uses modifier 57), or when the E/M is routine, bundled pre/post‑procedure care with no additional distinct work. Never apply 25 to non‑E/M codes.
Documentation payers typically expect: Clear records showing the E/M was significant and separately identifiable from the procedure — sufficient medical decision‑making or total time to support the E/M code, separate problem‑focused history/exam or counseling beyond usual procedure preparation, and explicit notes that justify billing the E/M as standalone.
Payer variability and scrutiny: Expect heightened review; Medicare generally pays appropriately when 25 is justified, but private payers and some Medicaid plans vary widely and may deny or reduce payment — be prepared to supply supporting documentation and appeal using AMA/CPT guidance.
Use examples only as guidance: Typical acceptable scenarios include a preventive visit with an unrelated acute problem requiring separate E/M care, or a procedure visit where substantial additional evaluation/counseling/problem management occurred and is documented as distinct from the procedure work.

Clinical Scenarios

Lesion removal with separate counseling: A patient presents for removal of a skin lesion (procedure). During the same visit the provider performs a significant, separately identifiable E/M visit — documents an extended problem‑focused history and exam, discusses possible malignancy, outlines additional diagnostic planning, and records distinct medical decision‑making beyond routine pre/postoperative care. The E/M code would be reported with modifier ‑25 alongside the procedure code (e.g., E/M code‑25 and the lesion removal code) to show the E/M was above and beyond the bundled procedure work.
Preventive visit plus new acute problem: A patient comes for a preventive/well visit and during the encounter reports new ear pain and fever. The clinician separately evaluates the acute complaint, documents a problem‑focused exam and medical decision‑making that could stand alone, and initiates treatment. The preventive medicine code is reported for the well visit and the separate problem‑focused E/M is reported with modifier ‑25 to indicate a significant, separately identifiable E/M service on the same day.
Procedure visit with additional unrelated E/M: A patient receives a minor office procedure (for example, an injection or minor wound care). In the same encounter the provider addresses an unrelated new complaint that requires an independent evaluation and management service (documented history, exam, and decision‑making beyond the procedure), and bills the E/M with modifier ‑25 in addition to the procedure code to reflect the distinct, billable E/M service.

References

Code	Name
22	Increased Procedural Services
23	Unusual Anesthesia Requirement
24	Unrelated Postoperative E/M Service
26	Professional Component Billing
27	Separate Same‑Day Outpatient E/M
32	Mandated Third-Party Services
33	Preventive Service (ACA)
47	Anesthesia Provided by Surgeon
50	Bilateral Procedure Billing
51	Multiple Procedures (Modifier -51)
52	Reduced Services (Provider Discretion)
53	Discontinued Procedure (Provider)
54	Surgical Care Only
55	Postoperative Management Only
56	Preoperative Management Only
57	Decision for Surgery
58	staged or related postop procedure
59	Distinct Procedural Service
62	Two Surgeons/Co‑Surgeons
63	Procedure on infant ≤ 4 kg

1.CPT® Codes and Descriptions. AAPC. Retrieved Aug 11, 2026.Maintains the CPT code set's official descriptions and guidelines, licensed from the American Medical Association, used as the definitional source for CPT codes on this page.
2.HCPCS Quarterly Update. Centers for Medicare & Medicaid Services (CMS). Retrieved Aug 11, 2026.CMS's quarterly release of HCPCS Level II codes and short/long descriptors, the source for HCPCS code definitions and update history.
3.ICD-10-CM Full Code List. Centers for Medicare & Medicaid Services (CMS). Retrieved Aug 11, 2026.CMS's complete ICD-10-CM diagnosis code list, used to cross-reference diagnosis codes associated with this procedure or service.

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Significant, Separately Identifiable E/M Service

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OpenPayer

Significant, Separately Identifiable E/M Service

Sign up for cpt_modifier 25 policy alerts

When to Use

Clinical Scenarios

Related Modifiers

References

When to Use

Clinical Scenarios

Related Modifiers

References

Significant, Separately Identifiable E/M Service

Sign up for cpt_modifier 25 policy alerts

Significant, Separately Identifiable E/M Service

Sign up for cpt_modifier 25 policy alerts

When to Use

Clinical Scenarios

Related Modifiers

When should modifier 25 be used on a claim?

What documentation do payers typically expect to support modifier 25?

When is modifier 25 commonly misused or inappropriate?

How does payer variability affect claims with modifier 25?

Can a preventive visit and a new acute problem be billed together using modifier 25?

References

When to Use

Clinical Scenarios

Related Modifiers

When should modifier 25 be used on a claim?

What documentation do payers typically expect to support modifier 25?

When is modifier 25 commonly misused or inappropriate?

How does payer variability affect claims with modifier 25?

Can a preventive visit and a new acute problem be billed together using modifier 25?

References