Modifiers · CPT modifier

Significant separately identifiable E/M

Modifier 25 signals that a physician performed a meaningful, distinct evaluation and management service on the same calendar day as a procedure or other service. The E/M must stand on its own clinical merit—separate work, separate documentation—beyond whatever assessment is routinely bundled into the procedure's pre- and post-service time.

Verified May 8, 2026 · 7 sources ↓

Type: CPT
CPT codes use it: 617
Top regions: Foot & ankle, Hand, Other

Drawn from AMACMSNovitasAAPCNethealth

When to use modifier 25

Source · Editorial brief grounded in 7 cited references ↓

Append modifier 25 to the E/M code (not the procedure code) when the physician's clinical work that day included a substantive patient assessment that went beyond the typical pre-procedure evaluation inherent in the procedure itself. Classic orthopedic scenarios include a patient presenting with a new knee complaint who undergoes both a thorough history and physical examination and a same-day joint injection or aspiration, or a patient seen for a scheduled follow-up who develops an unrelated acute problem—such as a suspected DVT after total knee arthroplasty—requiring a full separate work-up in addition to the planned visit. In both cases, the E/M effort is documented independently and is not simply the standard workup built into the procedure's global package.

Modifier 25 applies whether or not the E/M and the procedure share the same diagnosis. The AMA and CMS NCCI policy both confirm that different diagnoses are not required—what matters is that the clinical work is distinct and fully documented. For example, if an orthopedic surgeon evaluates a patient's shoulder rotator-cuff tear and separately assesses that patient's contralateral wrist fracture before performing a closed reduction on the same day, modifier 25 is appropriate even though two different body sites and diagnoses are involved.

One critical boundary: modifier 25 is for minor procedures and 'XXX'-global procedures performed on the same day. If the E/M leads to the decision to perform major surgery (90-day global), modifier 57 applies instead. Do not mix these two modifiers up—they serve different global-period contexts and payers will deny or downcode a claim that uses the wrong one.

Orthopedic scenarios

Concrete situations in orthopedic practice that warrant modifier 25.

Source · Editorial brief grounded in AAOS coding guidance and cited references ↓

A patient with established knee osteoarthritis presents for a scheduled corticosteroid injection (20610). During the visit the surgeon also performs a separate, documented evaluation of new lateral hip pain, orders imaging, and counsels the patient on treatment options. The E/M code (e.g., 99213 or 99214) is reported with modifier 25 to capture that distinct hip assessment.
A patient arrives in the ED after a motor vehicle accident. The orthopedic surgeon performs a complete history and physical examination, reviews imaging, and diagnoses a distal radius fracture, then performs a closed treatment with manipulation (25600). The E/M service (e.g., 99285-25) is separately reported because the evaluation went beyond the routine pre-procedure assessment built into the fracture management code.
During a post-operative arthroscopy follow-up visit within the 90-day global period, the surgeon identifies and evaluates a new, unrelated problem—an acute acromioclavicular joint sprain on the contralateral shoulder from a weekend fall. Because this is a completely separate problem outside the scope of the prior arthroscopy's global package, an E/M with modifier 25 may be warranted, though documentation must clearly delineate the two encounters.
A patient scheduled for removal of hardware after a prior ORIF tibial plateau repair (20680) also reports new symptoms of carpal tunnel syndrome in the contralateral hand. The surgeon performs and documents a separate upper-extremity neurologic examination and formulates a management plan. The E/M is billed with modifier 25 because the carpal tunnel evaluation is entirely unrelated to the hardware removal procedure.
An orthopedic surgeon sees a patient for a planned knee aspiration (20610) due to a suspected septic joint. In addition to the aspiration, the surgeon performs a detailed musculoskeletal and systemic examination to assess for systemic infection, orders labs, and makes disposition decisions. The substantive clinical reasoning and documented decision-making beyond the aspiration itself supports reporting the E/M with modifier 25.

Common mistakes

Where coders most often go wrong with modifier 25.

Source · Editorial brief grounded in CMS NCCI Policy Manual and cited references ↓

Appending modifier 25 to the procedure code instead of the E/M code—the modifier belongs on the E/M line only.
Using modifier 25 when the E/M is simply the standard pre-procedure assessment that is already bundled into the procedure's global period, such as the brief evaluation immediately before a trigger-point injection.
Substituting modifier 25 for modifier 57 when the E/M service on that day resulted in the decision to perform major surgery with a 90-day global period, such as deciding to proceed with open reduction internal fixation of a displaced femoral neck fracture.
Billing modifier 25 on CPT code 99211—CMS explicitly prohibits use of modifier 25 on 99211 because that code does not require a physician's presence and lacks the substantive E/M work the modifier presupposes.
Failing to create documentation that clearly distinguishes the E/M note from the procedure note; a single combined note that does not delineate separate history, examination, and medical decision-making for the E/M will not survive a payer audit.
Appending modifier 25 to HCPCS code G2211, which CMS prohibits—G2211 has its own distinct billing rules and is not eligible for modifier 25.
Assuming the E/M is separately payable simply because the patient is new; a new-patient status alone does not justify modifier 25 when the E/M work is inherently part of the procedure's standard workup.

CPT codes that use modifier 25

617 orthopedic CPT codes in our reference list this modifier as applicable. Sorted by total RVU.

Source · Derived from per-code modifier guidance in our CPT reference

Showing top 12 of 617 by total RVU.

Where modifier 25 shows up

Body regions where this modifier most commonly appears in our orthopedic reference.

Foot & ankle 118 codes
Hand 83 codes
Other 69 codes
Wrist 68 codes

Frequently asked questions

Source · Generated from the editorial pipeline, verified against 7 cited references ↓

01Do the E/M service and the procedure need to have different diagnoses to use modifier 25?

No—different diagnoses are not required. Both the AMA CPT guidelines and the CMS NCCI Policy Manual confirm that the E/M and the procedure can share the same diagnosis. What must be separate is the clinical work itself: the E/M must represent meaningful evaluation and management effort beyond what is bundled into the procedure's pre- and post-service work, and that work must be independently documented.

02Can modifier 25 be used during the global surgery period for a major procedure?

Modifier 25 is not the correct modifier when an E/M service leads to the decision to perform a major surgery with a 90-day global period—that scenario requires modifier 57. Within an existing global period, E/M services related to recovery from the surgery are already included in the global payment and cannot be separately billed with any modifier. Only unrelated E/M services during a global period may be separately reportable, typically using modifier 24.

03Where does modifier 25 get appended—on the E/M code or the procedure code?

Modifier 25 is always appended to the E/M code, never to the procedure code. Placing it on the procedure code is a claim error that will result in denial or incorrect payment. For example, if a surgeon performs a knee injection (20610) and a separate E/M (99214) on the same day, the claim line should read 99214-25, not 20610-25.

04Can modifier 25 be used on CPT code 99211?

No. CMS explicitly prohibits the use of modifier 25 on CPT code 99211. That code represents a minimal-service visit that does not require a physician's presence and lacks the substantive evaluation and management work that modifier 25 presupposes. Applying modifier 25 to 99211 will result in a claim denial under Medicare and most commercial payers that follow CMS guidance.

05What documentation is required to support modifier 25?

The medical record must contain a clearly delineated E/M note—separate from the procedure note—that includes a medically appropriate history, physical examination findings relevant to the condition being evaluated, and documented medical decision-making or time. The E/M documentation must stand on its own and demonstrate clinical work above and beyond the standard assessment bundled into the procedure. A single merged note that does not distinguish the two services is generally insufficient to withstand audit.

06How do NCCI procedure-to-procedure edits interact with modifier 25?

NCCI PTP edits identify procedure code pairs that should not be billed together because one service is considered bundled into the other. When both NCCI correct coding edits and global surgery edits apply to the same claim, CMS applies the correct coding edits first, then the global surgery edits. Modifier 25 can override certain PTP edits when the E/M is genuinely distinct and separately documented, but it cannot override edits that categorically prohibit separate billing regardless of modifier use. Always verify whether a specific code pair's PTP edit has a modifier indicator of '1' before assuming modifier 25 will unlock separate payment.

07Does modifier 25 apply differently in a facility setting versus a physician office?

The CPT definition of modifier 25 is identical in both settings, but facility billing rules—particularly under the Outpatient Prospective Payment System using Ambulatory Payment Classifications—can differ from physician billing rules and vary by payer. Some payers have their own facility-specific criteria for what constitutes a separately identifiable E/M in a hospital outpatient department or ED, so facilities must verify MAC and payer-specific guidance rather than assuming physician-side rules apply uniformly.

Sources & references

Editorial content was developed using the following public sources. Last verified May 8, 2026.

Mira AI Scribe

When an AI scribe is generating visit documentation that will support a modifier 25 claim, the note must clearly separate the E/M narrative from any procedure documentation. The E/M section needs its own discrete history of present illness, relevant review of systems, focused physical examination findings, and medical decision-making rationale that addresses the condition being evaluated—distinct from whatever assessment is inherent in the procedure performed. For orthopedic visits, this often means the scribe must document a separate clinical problem or a materially expanded evaluation of the presenting problem that goes well beyond standard pre-procedure prep. Notes that blend the E/M work into the procedure description—or that simply repeat the procedure indication as the 'assessment'—will not withstand payer audit. A well-structured AI-generated note should flag when both an E/M and a procedure are documented on the same date and prompt the provider to confirm and explicitly articulate the distinct clinical rationale for each service.

See how Mira flags modifier 25 in dictation