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Modifier 25: 2026 Medicare Billing Rules for E/M and Procedures

Last Updated: July 30, 2026

Modifier 25 is one of the most scrutinized modifiers by Medicare and commercial payers. It is used to report a "significant, separately identifiable Evaluation and Management (E/M) service by the same physician on the same day of a procedure or other service."

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When to Use Modifier 25

You can only use Modifier 25 on an E/M code (e.g., 99213, 99214). It tells the payer: "Yes, I did a procedure today, but I also performed a separate medical evaluation that went above and beyond the usual pre-op/post-op care for that procedure."

E/M CodeModifierProcedure Code
992142520610 (Joint Injection)

Medical Necessity and Different Diagnoses

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Don't risk a denial. See if your ICD-10 code is on the approved Medicare LCD list.

While Medicare does not strictly require a different ICD-10 diagnosis code to use Modifier 25, having a separate diagnosis makes your claim much stronger during an audit.

NCCI Edits and Modifier 25

Always run an NCCI check when billing an E/M with a procedure. If the procedure has a global period of 0 or 10 days (a "minor procedure"), the E/M will bundle into it and deny unless Modifier 25 is appended.

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