General Question for the Week of April 13, 2026

Question:

When is modifier 25 applicable?

Answer:

The 25 modifier is only applicable for reporting with an outpatient Evaluation and Management (E/M) visit code. This modifier is used to help bypass National Correct Coding Initiative (NCCI) edits when an outpatient E/M visit code is reported on the same date of service as a separately codable procedure or service. Below is the American Medical Association’s (AMA) definition for hospital outpatient use: Significant, Separately Identifiable Evaluation and Management Service by the Same Physician or Other Qualified Health Care Professional on the Same Day of the Procedure or Other Service: It may be necessary to indicate that on the day a procedure or service identified by a CPT code was performed, the patient’s condition required a significant, separately identifiable E/M service above and beyond the other service provided or beyond the usual preoperative and postoperative care associated with the procedure that was performed. A significant, separately identifiable E/M service is defined or substantiated by documentation that satisfies the relevant criteria for the respective E/M service to be reported (see Evaluation and Management Services Guidelines for instructions on determining level of E/M service). The E/M service may be prompted by the symptom or condition for which the procedure and/or service was provided. As such, different diagnoses are not required for reporting of the E/M services on the same date. This circumstance may be reported by adding modifier 25 to the appropriate level of E/M service. Note: For significant, separately identifiable non-E/M services, see modifier 59.