When should I Use it? 

Use Modifier 25 when:

• An E/M service is performed on the same day as a minor procedure (0- or 10-day global period)
• The E/M service goes above and beyond the usual preoperative and postoperative work of the procedure
• Documentation clearly supports medical necessity for the separate evaluation
• The E/M addresses a different problem OR requires significant additional work for the same problem

For facility outpatient billing, this typically applies when a hospital clinic or emergency department visit is distinct from the procedure performed.

When Not to Use

Do NOT use Modifier 25 when:

• The E/M is only the routine pre-procedure assessment
• The evaluation is minimal and inherent to the procedure
• There is no separate documentation supporting additional work
• The visit exists solely to perform the procedure

Modifier 25 should never be used to bypass bundling rules.

Common Denial Reasons

• Documentation does not support two distinct encounters
• Patient was never discharged between visits
• Second visit is related and continuous with first visit
• Modifier appended to physician claim instead of facility claim

Real-World Example

A patient presents to a hospital outpatient clinic for a scheduled follow-up in the morning.

Later that same day, the patient develops chest pain and presents to the emergency department.

If both visits are separately documented and medically necessary, the hospital may append Modifier 27 to the second E/M service.

CMS Guidance

CMS allows Modifier 27 to identify multiple outpatient hospital E/M encounters on the same date.

Key CMS principles:

• Applies to hospital outpatient claims only
• Not reported by physicians
• Encounters must be distinct and medically necessary
• Documentation must support separate visits

Modifier 27 is recognized under the Outpatient Prospective Payment System (OPPS).