CurrentPremera BluecrossPolicy CP.PP.101.v3.0

Modifier 25 — Significant, Separately Identifiable E&M Service on Same Day of Procedure or Other Service

Defines when Premera recognizes evaluation and management (E&M) services billed with modifier 25 on the same date as a procedure or other service for professional claims; applies to Premera Blue Cross, Premera BCBS of Alaska, LifeWise Health Plan of Washington, LifeWise Assurance Company and Premera Blue Cross HMO lines of business and products.

Policy Summary

PayerPremera Bluecross

PolicyModifier 25 — Significant, Separately Identifiable E&M Service on Same Day of Procedure or Other Service

Policy CodePolicy CP.PP.101.v3.0

Change TypeClarifications and minor revisions

Effective Date

Next Review Date

Key ActionAppend modifier 25 only to E&M codes when the E&M is significant and separately identifiable and ensure documentation supports the separate service.

SourceLink

POLICY UPDATE CHANGES

Clarified criteria in the first and last paragraphs of the 'Policy' section.

Added a cross reference to policy 'Screening Services with Evaluation and Management Services'.

Clarified the Purpose statement to indicate that the policy pertains to Professional services billed on a CMS-1500 or 837P electronic claim forms.

Added clarification that appending modifier 25 does not result in automatic reimbursement unless supported by documentation in the medical record.

Minor revisions to identify global days for minor and major surgical procedures.

5covered lines of business named

CP.PP.101.v3.0document identifier

2025-08-04last review

2004-2025version span

Modifier 25 — Coverage Criteria

Modifier 25 coverage criteria

Covered when ALL of the following are met:

Compliance & exceptions

Violations of this policy may result in increased auditing and monitoring, contractual penalties, corrective action up to termination, or employment termination as applicable.
Exceptions to the policy may be made where a provider or employer group contract dictates otherwise.

References: See AMA CPT, CMS, NCCI guidelines and OIG report 'Use of Modifier 25' for supporting references.

Coding Guidance and Global Periods

Relevant modifiersModifier

25	Modifier 25 - Significant, separately identifiable E&M service
57	Modifier 57 - Decision for Surgery (use instead when E&M resulted in decision for major surgery)

Policy Summary

PayerPremera Bluecross

PolicyModifier 25 — Significant, Separately Identifiable E&M Service on Same Day of Procedure or Other Service

Policy CodePolicy CP.PP.101.v3.0

Change TypeClarifications and minor revisions

Effective Date

Next Review Date

Key ActionAppend modifier 25 only to E&M codes when the E&M is significant and separately identifiable and ensure documentation supports the separate service.

SourceLink

On This Page

Global period guidance

Do not append modifier 25 when E&M resulted in decision for major surgeryUse modifier 57 instead for E&M services that resulted in the decision to perform a major surgery (90‑day global period)

Do not append modifier 25 for visits solely for minor surgical proceduresDo not append modifier 25 when the E&M was performed on the same day as a minor surgical procedure (0 or 10 global days) if the visit was solely for the minor procedure

Modifier 25 limited to E&M codesModifier 25 may be appended only to E&M CPT codes and not to other procedure codes

Documentation requirementAppending modifier 25 does not guarantee payment; medical record documentation must support that the E&M was significant, separately identifiable, and distinct from the other service

No 25 when no other service billedDo not append modifier 25 if no other service was performed and billed on the same date of service

Global day durations notedMajor surgery: 90‑day global period; Minor procedures: 0‑ or 10‑day global periods

Provider Billing and Documentation Actions

Documentation Required

Modifier 25 usage and documentation requirements

Modifier 25 should only be appended to Evaluation and Management (E&M) codes to indicate a significant, separately identifiable E&M service performed by the same physician or qualified healthcare professional on the same date of service as another procedure or service. Documentation must be available in the patients medical record and must clearly demonstrate that the E&M service was above and beyond the usual pre- and post-operative care associated with the procedure and is distinct from documentation for the other service(s). Supporting documentation should be made available for review upon request.

Applies only to E&M CPT codes.
Documentation must show the E&M service was significant, separately identifiable, and distinct from the procedure-related care.
Modifier 25 does not automatically guarantee payment; the record must support separate billing.

Billing Rule

When not to use modifier 25

Do not append modifier 25 when an E&M visit resulted in the decision to perform a major surgery (global period 90 days). Instead, append modifier 57 (Decision for Surgery) to the E&M service where the decision for major surgery was made. Do not append modifier 25 when the E&M visit on the same day was solely for the performance of a minor surgical procedure (global days 0 or 10). Also, do not append modifier 25 if no other service was performed and billed on the same date of service.

Use modifier 57 (Decision for Surgery) for E&M services that resulted in the decision for major surgery (90-day global period).
Do not use modifier 25 for visits that were solely for a minor procedure (0- or 10-day global period).
Do not use modifier 25 when no other service/procedure was billed on the same date of service.

Key Definitions

Modifier 25 — definition

DefinitionModifier 25 indicates a significant, separately identifiable E&M service performed by the same physician or other qualified healthcare professional on the same date as a procedure or other service, above and beyond usual pre‑ and post‑operative care

Applicable codesModifier 25 is appended only to E&M codes

Documentation expectationUse of modifier 25 indicates documentation is available in the patient record to support the service being billed as significant and separately billable and clearly distinct from documentation for the other procedure(s)

Payment caveatAppending modifier 25 will not automatically allow payment; reimbursement depends on documentation and claims adjudication

Modifier 57 — definition

DefinitionModifier 57 indicates that the E&M service resulted in the decision to perform a major surgery (90‑day global period)

Use instead of 25Do not use modifier 25 if the E&M resulted in the decision for major surgery; add modifier 57 to the E&M service

Global periodAssociated with a 90‑day global surgical period