CurrentPremera BluecrossPolicy N/A

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

Defines when Premera recognizes E&M services appended with modifier 25 on professional claims and the documentation requirements; 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.

Policy Summary

PayerPremera Bluecross

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

Policy CodePolicy N/A

Change TypeMaterial clarifications and additions

Effective DateN/A

Next Review DateN/A

Key ActionAppend modifier 25 only to E&M codes when a significant, separately identifiable E&M service was performed on the same date as another procedure/service and ensure documentation supports the separate nature.

SourceLink

POLICY UPDATE CHANGES

Added 'XXX' procedures to the list where an E&M with modifier 25 is not appropriate when the visit is solely for the performance of the procedure.

Clarified that appending modifier 25 does not automatically allow payment unless documentation supports the significant, separate nature of the E&M service.

Specified modifier 25 should not be used when the E&M resulted in the decision to perform a major surgery; modifier 57 should be added in those cases.

5lines of business covered

Multiplepolicy review activity

AMA/CMS/NCCI/OIGauthoritative references cited

When Modifier 25 Is Recognized

Modifier 25 coverage criteria

Covered when ALL of the following are met:

Must be an E&M code with modifier 25 appended

E&M service is significant, separately identifiable, and represents services above and beyond the other service(s) provided or beyond the usual pre- and post-operative care associated with the procedure

Documentation in the patient record supports the significant, separate, and distinct nature of the E&M service and is available for review; appending modifier 25 does not automatically guarantee payment

Modifier 25 is only appended when another procedure or service was performed and billed on the same date of service

Do not use modifier 25 when the E&M resulted in the decision to perform a major surgery (90 global days); instead append modifier 57

Policy Summary

PayerPremera Bluecross

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

Policy CodePolicy N/A

Change TypeMaterial clarifications and additions

Effective DateN/A

Next Review DateN/A

SourceLink

On This Page

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

Documentation, Correct Modifier Use, and Compliance

Documentation Required

Documentation and correct modifier usage

Append modifier 25 only to E&M codes when a significant, separately identifiable E&M service was performed on the same date as another procedure or service; the documentation must support that the E&M was above and beyond the usual pre- and post-operative care and be available for review. Do not use modifier 25 when the E&M resulted in the decision to perform a major surgery (use modifier 57), when the visit was solely for a minor surgical procedure (0 or 10 global days), when the visit was solely for a procedure with an 'XXX' global surgery indicator, or when no other service was performed and billed the same date.

Modifier 25 is appended only to E&M codes.
Documentation must be clearly distinct from documentation related to the other procedure(s) and available for review.
Use modifier 57 when the E&M resulted in the decision for major surgery (90 global days).
Do not append modifier 25 if no other service was performed and billed on the same date.

Denial Risk

Compliance consequences

Violations of this policy by any party that has a written arrangement with the Plan may result in increased auditing and monitoring, performance guarantee contractual penalties, and/or termination of the contract; disciplinary actions will be determined based on the seriousness of the violation.

Increased auditing and monitoring.
Performance guarantee contractual penalties.
Termination of contract; disciplinary actions appropriate to severity.

Modifier 25 — Meaning and Limitations

Definition of Modifier 25

DefinitionModifier 25 — an indicator appended to an E&M code to signify a significant, separately identifiable E&M service performed by the same physician or qualified healthcare professional on the same date as a procedure or other service.

PurposeDenotes an E&M that is above and beyond the other service(s) provided or beyond usual pre-/post-operative care.

DocumentationUse of modifier 25 indicates documentation is available in the patient record to support the E&M as significant, separate, and distinct from the other procedure(s); documentation must be available for review.

When Modifier 25 is not appropriate

Decision for major surgeryDo not use modifier 25 when the E&M resulted in the decision to perform a major surgery (90 global days); add modifier 57 instead.

Minor surgical proceduresDo not append modifier 25 when the visit was solely for a minor surgical procedure (0 or 10 global days).

Procedures with 'XXX' global indicatorDo not append modifier 25 for a procedure with an 'XXX' global surgery indicator when the patient’s visit was solely for performance of that procedure.

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

OpenPayer

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

When Modifier 25 Is Recognized

Modifiers and Code Scope

Documentation, Correct Modifier Use, and Compliance

Modifier 25 — Meaning and Limitations

25	Modifier 25 — significant, separately identifiable E&M service by the same physician on same day as procedure
57	Modifier 57 — decision for surgery (use when E&M results in decision for major surgery)