CurrentPremera BluecrossPolicy N/A

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

Defines when Premera recognizes an evaluation and management (E&M) service billed with modifier 25 on the same date as another procedure or service and applies to applicable Premera and affiliated 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 N/A

Change TypeMaterial updates and clarifications

Effective DateN/A

Next Review DateN/A

Key ActionAppend modifier 25 only when documentation supports a significant, separately identifiable E&M on the same day as another service; do not use when E&M resulted in decision for major surgery (use modifier 57) or when visit was solely for certain minor/XXX procedures.

SourceLink

POLICY UPDATE CHANGES

Added 'XXX' procedures to the list in the policy section 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 result in automatic reimbursement unless supported by documentation in the member's medical record.

Clarified criteria regarding when modifier 25 should not be used for E&M services related to global surgical periods (major surgery decision should use modifier 57).

MultipleAffiliates covered

RequiredDocumentation requirement

05/12/26Last approval

AnnualReview frequency

Modifier 25 Coverage Criteria

Modifier 25 coverage criteria

The Plan recognizes modifier 25 when the following conditions are met:

Service billed must be an E&M code with modifier 25 appended.

Documentation in the patient record must support that the E&M was significant, separately identifiable, and distinct from the other procedure/service documentation.

Appender must ensure documentation is clearly distinct from documentation related to the other procedure(s) performed on the same date and available for review.

Do not append modifier 25 when any of the following apply:

The E&M resulted in the decision to perform a major surgery (use modifier 57 instead).

Policy Summary

PayerPremera Bluecross

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

Policy CodePolicy N/A

Change TypeMaterial updates and clarifications

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.

Relevant Modifiers and Global-day Guidance

Modifiers referencedModifier

25	Modifier 25 - Significant, separately identifiable E&M service on same day of procedure or other service
57	Modifier 57 - Decision for surgery (use instead of 25 when E&M resulted in decision for major surgery)

Global day restrictions and modifier 25 use

When NOT to append modifier 25Do not append modifier 25 if the E&M resulted in the decision to perform a major surgery (use modifier 57 instead).

Minor procedure/global day restrictionDo not append modifier 25 for E&M performed on same day as a minor surgical procedure with 0 or 10 global days when the visit was solely for the procedure.

XXX global surgery indicatorDo not append modifier 25 for procedures with an XXX global surgery indicator when the visit was solely for the performance of the procedure.

Standalone E&M ruleDo not append modifier 25 if no other service was performed and billed on the same date of service.

Documentation requirementAppending modifier 25 does not automatically allow payment; documentation must support that the E&M was significant, separate, and distinct and must be available for review.

Documentation and Billing Guidance for Providers

Billing Rule

Provider documentation and billing guidance for modifier 25

Append modifier 25 only to E&M codes when the medical record documents a significant, separately identifiable E&M service on the same date as another procedure or service; ensure documentation is clearly distinct from the other service and available for review. Do not use modifier 25 when the E&M resulted in the decision to perform major surgery (use modifier 57) or when the visit was solely for a minor surgical procedure (0 or 10 global days) or a procedure with an XXX global surgery indicator. Appending modifier 25 does not guarantee payment — adjudication and documentation review determine reimbursement.

Modifier 25 may only be appended to E&M codes and must be supported by documentation showing the E&M was above and beyond usual pre- and post‑operative care.
Use modifier 57 instead of 25 when the E&M resulted in the decision for major surgery (90‑day global).
Do not append modifier 25 if the visit was solely for a minor procedure (0 or 10 global days) or a procedure with an XXX global surgery indicator.
Modifier 25 should not be appended if no other service was performed and billed on the same date of service.

Modifier Definitions

Definition of modifier 25

DefinitionModifier 25: appended only to E&M codes to indicate a significant, separately identifiable E&M service performed by the same practitioner on the same date as another procedure or service, beyond usual pre- and post-operative care.

Scope of useUse only on E&M codes submitted on a professional claim when documentation supports a service above and beyond other services provided on the same date.

Documentation expectationUse of modifier 25 indicates documentation is available in the patient record that clearly distinguishes the E&M from the procedure/service and is available for review.

Definition of modifier 57

DefinitionModifier 57: Decision for Surgery — should be added to an E&M service when the E&M resulted in the decision to perform a major surgery (90-day global).

When to use instead of 25Use modifier 57 rather than modifier 25 when the E&M visit results in the decision for major (90-day global) surgery.

Relation to global periodsModifier 57 specifically indicates the decision for major surgery associated with a 90-day global period.