Complete Story
04/01/2026
2nd Quarter Billing Buzz from Zone 1
Modifier 25 or No Modifier 25: That is the Question
Modifier 25 or No Modifier 25: That is the Question
Recently Blue Cross Blue Shield and Blue Care Network announced a change in how they will process evaluation and management (E/M) services appended with a modifier 25 billed in conjunction with non-preventative services. The February 2026 edition of The Record stated that beginning May 1, 2026 the E/M service will be reimbursed at 50% of contracted rates instead of the current process which reduces payment of the non-preventative service by 50%.
This change is just one of many reasons it is important to know when to use modifier 25 and when not to. The misuse of the modifier could result in a loss in profit, delayed payments due to the rework of denied claims and an increased risk of audits.
When to Use Modifier 25
Modifier 25 is used to indicate additional E/M work beyond the usual scope of the procedure or service performed. The American Medical Association (AMA) explains the modifier is appropriately appended when the E/M is:
- Performed by the same provider on the same day on the same patient.
- Significant and separately identifiable from the other procedure or service.
- Medically necessary based on the patient’s condition.
- Clearly supported by documentation that can stand on its own as a billable service.
Common Mistakes
To fully understand when to use modifier 25, it is important to understand when not to use it. According to the AMA, some common errors include:
- Appending the modifier to services that are not E/M services.
- Using the modifier to bill for services that are considered components of the primary service rendered.
- Adding the modifier to bill for simple, routine or minor procedures that are typically bundled with the E/M.
- Using modifier 25 when another modifier is more appropriate.
- Adding the modifier when documentation does not fully support its use.
Tips For Use
To help prevent the misuse of modifier 25 and the negative consequences that come with it, here are a few tips:
- Verify individual policies of the payers. Each payer has their own interpretation of the guidelines for use of the modifier.
- Review documentation to ensure all components of the focused E/M have been documented and can stand alone as a separate billable service.
- Review the claim to verify accuracy of the modifier placement and diagnosis codes assigned to the E/M.
- Educate providers on the importance of documenting the medical decision making that goes above and beyond the inherent E/M included in the procedure or service and clearly shows the medical necessity of the separately billed E/M.
https://www.ama-assn.org/system/files/reporting-CPT-modifier-25.pdf
