Modifier reference · Updated Aug 6, 2026

Modifier 25

Modifier 25 tells Medicare that an evaluation and management (E/M) service performed on the same day as another procedure or service was significant and separately identifiable. It belongs on the E/M line and does not by itself increase the Physician Fee Schedule amount.

When Medicare expects modifier 25 Copy link

Use modifier 25 on an E/M code when the same physician or qualified non-physician practitioner provides the same patient a medically necessary E/M service and another procedure or service on the same date, and the E/M work is significant and separately identifiable beyond the work normally included in the other service. In Medicare claims processing that situation arises with same-day procedures that would otherwise bundle the visit — minor surgical procedures with 0- or 10-day global periods, and services subject to NCCI procedure-to-procedure edits against E/M codes. The record must support both services. Medicare does not require different diagnoses solely to report the separate E/M service.

When modifier 25 is not needed Copy link

A same-day clinical laboratory test does not by itself require modifier 25 on the visit: lab tests carry no global period and have no NCCI edits bundling them into office/outpatient E/M codes, so there is nothing for the modifier to bypass. Appending it anyway is not harmless — a reflexive modifier 25 added for a lab or another service outside CMS’s preventive exception strips payment for the G2211 ongoing-care add-on. For dates of service on or after January 1, 2025, vaccine administration is explicitly inside that exception; for 2024 dates of service, any modifier 25 on the base visit still blocks G2211. Billing systems that auto-append modifier 25 whenever any second service appears on the claim are a common cause of avoidable G2211 denials.

What modifier 25 changes Copy link

Modifier 25 tells the claims system to consider the E/M service separately; it is not a percentage payment adjustment and does not create a higher fee-schedule amount for the E/M code. It is also different from modifier 59 and the X{EPSU} modifiers used for eligible NCCI procedure-to-procedure edits.

The G2211 exception Copy link

Medicare generally denies G2211 when its office/outpatient E/M base visit is reported with modifier 25 on the same date, for the same patient, by the same practitioner. Beginning January 1, 2025, a narrow exception applies when the same-day service is an annual wellness visit, vaccine administration, or another service on CMS’s allowed Part B preventive-service list. Other modifier-25 combinations remain subject to the denial. Ordinary Part B deductible and coinsurance apply to G2211; the add-on code is not itself a preventive service with waived cost sharing.

Where the modifier goes Copy link

Append modifier 25 to the qualifying E/M line, not to the procedure, vaccine-administration, preventive-service, or G2211 line. The modifier identifies the separate E/M work; it does not establish medical necessity on its own.

Proposed for 2027 Copy link

The CY2027 PFS proposed rule (published July 16, 2026) would reduce payment for an office/outpatient E/M visit reported with modifier 25 on the same day as a 0-, 10-, or 90-day global procedure by the same physician or group. The same rule proposes replacing G2211 with percentage-based modifiers while keeping the current modifier-25 limitations. Both are proposals, not final policy — check the final rule (expected around November 2026) before applying either to 2027 dates of service.

Frequently asked Copy link

Which claim line gets modifier 25?

The qualifying E/M line. Do not append it to the other procedure or service merely because both occurred on the same date.

Do I need modifier 25 when the visit is billed with a lab test?

No. Clinical laboratory tests have no global period and no NCCI edits against office/outpatient E/M codes, so a same-day lab does not require the modifier — and adding it unnecessarily blocks payment of the G2211 add-on.

Does modifier 25 increase the Medicare fee schedule amount?

No. Modifier 25 allows the separately identifiable E/M service to be considered for payment, but it does not apply a percentage or dollar adjustment to that service.

Can G2211 be billed when the base visit has modifier 25?

Generally no. Since January 1, 2025, Medicare allows a narrow exception when the same-day service is an annual wellness visit, vaccine administration, or another service on its allowed Part B preventive-service list.

Does Medicare require a different diagnosis for the E/M service?

No. The documentation must support a significant, separately identifiable and medically necessary E/M service, but Medicare does not require a different diagnosis solely because modifier 25 is used.

Sources Copy link

Written from primary CMS sources — see how we source, compute, and verify everything on this site.

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