Short answerModifier 25 is allowed when the provider performs a significant, separately identifiable E/M service on the same day as a minor procedure (0 or 10-day global), beyond the usual pre- and post-procedure evaluation. The decision to perform a minor procedure alone does not justify a separate E/M.
Orthopedic visits often combine an evaluation with an injection or other minor procedure. Payers routinely deny the E/M unless the documentation shows it stood on its own.
Modifier 25 vs modifier 57
| Modifier | Use | Global period of the procedure |
|---|---|---|
| 25 | Significant, separately identifiable E/M on the same day as a minor procedure | 0 or 10 days |
| 57 | E/M that resulted in the decision to perform major surgery, the day before or day of | 90 days |
When modifier 25 is supported
- a new problem evaluated in addition to the injected joint
- a significant worsening needing a full workup beyond the procedure
- management of a separate condition at the same visit
When it isn't
- the visit only decides to do the planned injection
- routine pre-procedure assessment
- a follow-up visit already included in a global period (that needs 24 if unrelated)
Documentation tips
- separate the E/M assessment and plan from the procedure note
- list the distinct problem addressed
- support the E/M level on its own merits
Related: orthopedic billing.
This article is general billing information, not legal or coding-compliance advice. Payer rules, CPT descriptors and federal guidance change; check the current versions for your claims.