Modifier 25: The Drama Never Ends
Article Reference Code: NAMAS.05.08.2026
Written by: Angela Clements, CPC, CPMA, CPC-M, CEMC, CGSC, COSC, CCS, AAPC Approved Instructor
Modifier 25 is used when documentation supports a “significant, separately identifiable evaluation and management (E/M) service by the same physician or other qualified health care professional on the same day of a procedure or other service.” It seems straightforward, so why is there so much drama surrounding its usage? It has been around for decades; by now, we should be pros at applying it.
Currently, many large organizations are allowing providers to code their own clinic visits rather than staffing a dedicated department to code those services. This shift has changed the coder’s responsibilities; they are now primarily working on system-generated edits. While technology is a great tool that assists coders in their duties, we must ensure it is used appropriately. Technology is only as effective as its programming, and coders and auditors must still use their expertise to accurately code and audit services.
Coders are expected to maintain specific productivity levels, which isn’t inherently bad, but some coders are taking shortcuts to meet those goals. For example, a coder may receive an edit suggesting they append modifier 25 to an E/M service performed on the same day as another service. To bypass the edit and get the claim out the door, the coder might append the modifier without actually reviewing the documentation.
When an internal quality assurance (QA) audit is performed, it is often determined that the modifier was applied incorrectly—specifically in cases where the patient arrived for a scheduled procedure and the documentation did not support a significant and separately identifiable E/M service. In an external audit, if an insurer determines the documentation is insufficient, they will recoup the payment without question.
Auditors and educators are responsible for training both coders and providers. Modifier 25 is likely the second most abused modifier in medical billing, and insurance companies are scrutinizing these claims heavily. Several years ago, insurers even began announcing prepayment audits for any claim featuring modifier 25.
When providers are educated on the incorrect use of the modifier, they often respond, “But we got paid for it.” As auditors, we know that payments are made in good faith that the documentation supports the claim. We also know that just because you received reimbursement doesn’t mean you are entitled to keep it.
In 2025, The OIG release an audit performed on 2023 claims for Evaluation and Management Services Provided on the Same Day as Eye Injections. The OIG found:
- “For 42 percent of intravitreal injections provided during our audit period, providers billed for E&M services provided on the same day as injections using modifier 25, which allowed the claims to bypass system edits that are designed to prevent improper payments.
- To test provider compliance with Medicare requirements, we reviewed documentation for 24 sampled E&M services and found that documentation for 22 services did not support the use of modifier 25.
- CMS paid for E&M services billed with modifier 25 and provided on the same day as intravitreal injections that were at risk for noncompliance because CMS’s internal controls were not adequate during our audit period to detect and prevent potentially improper payments. During our audit period, Medicare paid $124 million nationwide for these services.”
Notice the second bullet. Out of 24 sampled, 22 did not support. That is almost all of the reviewed sample.
How do we protect our organization? We must thoroughly understand Modifier 25 and its appropriate application. It is vital to recognize that procedures or services with 000, 010, or 090 global days already have an E/M component built into their reimbursement.
The NCCI manual Chapter 1 states, “If a procedure has a global period of 000 or 010 days, it is defined as a minor surgical procedure. In general, E&M services performed on the same date of service as a minor surgical procedure are included in the payment for the procedure. The decision to perform a minor surgical procedure is included in the payment for the minor surgical procedure and shall not be reported separately as an E&M service. However, a significant and separately identifiable E&M service unrelated to the decision to perform the minor surgical procedure is separately reportable with modifier 25. The E&M service and minor surgical procedure do not require different diagnoses. If a minor surgical procedure is performed on a new patient, the same rules for reporting E&M services apply. The fact that the patient is “new” to the provider/supplier is not sufficient alone to justify reporting an E&M service on the same date of service as a minor surgical procedure”
Resources like the NCCI manual and the AMA’s ‘Reporting CPT Modifier 25’ are essential tools for any coding professional. Use them to educate yourself and your organization. Ultimately, knowledge is our best defense; it ensures correct coding and protects reimbursement when properly understood and utilized to reduce the risk on recoupment during an audit.
Additional Resources:
https://www.ama-assn.org/system/files/issue-brief-cms-modifier-25.pdf
https://www.ama-assn.org/system/files/reporting-CPT-modifier-25.pdf
https://www.cms.gov/files/document/01-chapter1-ncci-medicare-policy-manual-2026-final.pdf
https://www.novitas-solutions.com/webcenter/portal/MedicareJL/pagebyid?contentId=00097341
https://med.noridianmedicare.com/web/jeb/topics/modifiers/25
https://palmettogba.com/jmb/did/8eelf54813?cat=jmb-claims
Contact Angela on LinkedIn by Clicking her Name Below:
Angela Clements, CPC, CPMA, CPC-M, CEMC, CGSC, COSC, CCS, AAPC Approved Instructor
Angela Clements is a physician coding auditor, educator, and consultant at MedKoder. She has 25 years of experience in the healthcare industry. Clements served on the AAPC National Advisory Board (2013–2018) and now serves on the AAPC Subject Matter Expert Advisory Committee. She is also chair of the AAPC Ambassador Committee, member of the AAPC Exam and Certification Committee and is an AAPC VILT instructor for the CPC® course. Clements is one of the founding members of the Covington, Louisiana local chapter and has served in many officer positions. She has also published several articles for AAPC and is a frequent speaker both locally and nationally for multiple organizations.
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