What is modifier 25, and when should it be used? Modifier 25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) should be appended to an Evaluation and Management (E/M) code when a significant, separately identifiable E/M service is performed by the same physician or other qualified health care professional on the same day as a procedure.
How does modifier 25 apply to otolaryngology-head and neck surgery procedures?
Modifier 25 should be appended to an E/M code when an E/M service is performed on the same day as another service or procedure, and when the E/M service goes above and beyond the usual pre-service, intra-service, and post-service care associated with the service or procedure.
This scenario commonly arises in otolaryngology-head and neck surgery practices. For example, a patient may present with sinus complaints, undergo a comprehensive evaluation, and also have a diagnostic nasal endoscopy performed during the same visit. If this “comprehensive evaluation” included a history, exam, and medical decision-making that exceeds the typical pre-procedure work associated with diagnostic nasal endoscopy, the E/M code may be reported with modifier 25, provided the documentation supports medical decision-making beyond the typical assessment associated with the procedure itself.
When should modifier 25 not be used?
Importantly, modifier 25 should never be used automatically. This modifier is frequently flagged by payers for inappropriate use, so the medical record must clearly demonstrate that the E/M service was distinct and medically necessary. Also, modifier 25 should not be used when billing for E/M services performed during a post-operative period if the E/M service is related to the previous surgery.
Can modifier 25 be appended to a procedure code?
No, modifier 25 should never be appended to a procedure code. It must only be appended to E/M service codes to indicate a significant, separately identifiable E/M service performed by the same physician on the same day as a procedure. For more information on reporting distinct procedural services performed on the same date of service, please reference the Academy’s CPT for ENT article on modifier 59.
Can modifier 25 be billed with the G2211 add-on code?
In most cases, no. However, for Medicare beneficiaries, beginning January 1, 2025, CMS allows payment for G2211 in certain circumstances when an office/outpatient E/M service is reported with modifier 25 on the same date as an annual wellness visit, vaccine administration, or certain Medicare Part B preventive services.
Does using modifier 25 decrease reimbursement?
In most cases, no. The Medicare Claims Processing Manual, Chapter 12, section 30.6.6 states that payment may be provided for “an E/M service provided on the day of a procedure with a global fee period if the physician indicates that the service is for a significant, separately identifiable E/M service that is above and beyond the usual pre- and post-operative work of the procedure.”
However, the Academy is aware of some commercial payers who are applying a blanket reduction for E/M services reported with modifier 25 when furnished on the same date as another procedure. For payers who enforce this policy, they often pay 100% of the procedure and 50% of the allowed amount for the E/M service.
The Academy strongly disagrees with these types of policies, as they threaten patient care by discouraging necessary, same-day services. The resource-based relative value scale (RBRVS) methodology, which underpins physician payment, accounts for physician work, practice expense, and malpractice inputs in a manner that prevents overlap between the work associated with a procedure and a properly reported, separately identifiable E/M service. If you are experiencing this type of blanket payment reduction, please contact the Academy’s Health Policy Advocacy Team at [email protected].
Does the Academy offer any other resources on modifier 25?
If you are experiencing denials or payment reductions for services appended with modifier 25, the Academy offers a template letter to assist AAO-HNS members in drafting appeals: https://www.entnet.org/wp-content/uploads/2025/03/Template_Appeal_Letter-Modifier_25-March2025.pdf
Questions about billing and coding using modifier 25? Contact the Academy’s Health Policy team: [email protected].
Published July 2026
