Modifier 25 — Significant, Separately Identifiable E&M Service on Same Day as Procedure or Other Service
Defines when Premera recognizes and will consider reimbursement for an evaluation and management (E&M) service appended with modifier 25 when billed on the same date as another procedure or service; applies to professional claims across Premera and affiliated lines of business.
Added clarification on the correct use of modifier 25 indicating that appending modifier 25 does not result in automatic reimbursement unless supported by documentation in the member's medical record.
Clarified the Purpose statement to indicate that the policy pertains to Professional services billed on a CMS-1500 or 837P electronic claim forms.
In the Policy section, minor revisions to identify global days for minor and major surgical procedures.
Recognition and Reimbursement Criteria
Recognition and reimbursement criteria for modifier 25
The Plan will recognize modifier 25 on professional claims only when documentation supports that the E&M service was significant and separately identifiable from other services or usual pre-/post‑operative care.
ALL of the following
Do not use modifier 25 when:
- The E&M service resulted in the decision to perform a major surgery (90‑day global period); use modifier 57 instead.
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.