Medicare denials for office visits are on the rise—and Modifier 25 is one of the biggest culprits. If your practice is experiencing denials for E/M services billed on the same day as procedures, you’re not alone. In 2023, multiple Medicare Administrative Contractors (MACs) ramped up pre-payment edits and post-payment reviews targeting misuse of Modifier 25, and the trend has continued into 2025.
So how do you use Modifier 25 correctly? And more importantly—which code gets the modifier when an E/M visit and procedure are billed together?
This blog breaks it down with actionable denial management strategies, real-world guidance based on current CMS guidelines, and a mini case study to show it in action.
Why Medicare Denies Modifier 25 Claims
Denial Type: CO-18 – Duplicate claim/service; CO-151 – Payment adjusted because the payer deems the information submitted does not support this level of service
Why It Happens:
- Modifier 25 is added incorrectly or missing altogether
- The documentation doesn’t support a separate, significant E/M service
- Modifier 25 is applied to the wrong code (e.g., the procedure instead of the E/M)
- Global periods are misunderstood or ignored
- Payers apply automated edits to deny “unbundled” services
Medicare’s 2024 Program Integrity Manual emphasizes that Modifier 25 must not be used to bypass CCI edits and must reflect clinically distinct and separately documented services.
What CMS Says About Modifier 25 (as of 2025)
According to CMS guidelines and NCCI Policy Manual Chapter 1, Modifier 25 should only be appended to Evaluation and Management (E/M) services when:
- A significant, separately identifiable E/M service was performed on the same day as a minor procedure (0- or 10-day global period)
- The E/M service is above and beyond the usual preoperative and postoperative care associated with the procedure
- The provider documents this distinct evaluation clearly in the medical record
Important: Modifier 25 goes on the E/M code, not the procedure. This is one of the most common billing errors and a frequent trigger for denials.
5 Tactics to Prevent Modifier 25-Related Denials
## 1. Place Modifier 25 on the E/M Code—Always
Why It Matters:
Many practices mistakenly apply Modifier 25 to the procedure code. This is a red flag for Medicare edits and will lead to automatic denial.
Implementation Tips:
- Train billers and coders to only append Modifier 25 to E/M codes (e.g., 99213, 99214)
- Never use Modifier 25 on procedural CPT codes (e.g., 11721, 36415)
- Pair with correct ICD-10 codes that justify both services distinctly
Quick Win: Add EHR prompts that auto-suggest Modifier 25 only on E/M CPTs during same-day procedures.
## 2. Ensure Documentation Supports Medical Necessity
Why It Matters:
Without clear evidence that the E/M was medically necessary separate from the procedure, your claim won’t survive audit or appeal.
Implementation Tips:
- Use separate headings in the note for E/M and procedure
- Document patient history, physical exam, and medical decision-making tied to a distinct problem or condition
- Ensure time-based documentation if counseling dominates the visit
Quick Win: Create templated phrases in your EHR for Modifier 25 scenarios that require individualized reasoning.
## 3. Review CCI Edits Before Submitting Claims
Why It Matters:
CMS uses the Correct Coding Initiative (CCI) to flag bundled services. Even with Modifier 25, some combinations are not billable together.
Implementation Tips:
- Check CCI edits via the CMS NCCI Edit Lookup Tool
- Flag high-risk pairs like 99213 + 36415 or 99214 + 17000 for manual review
- Develop a quick-reference grid for providers and coders
Quick Win: Set denial alerts in your billing software for common Modifier 25-related CCI edit pairs.
## 4. Use Internal Audits to Catch Pattern Errors
Why It Matters:
Medicare contractors are increasing targeted audits on providers with high Modifier 25 usage rates—especially when usage exceeds 70% of E/M claims.
Implementation Tips:
- Run monthly Modifier 25 utilization reports by provider
- Audit 10 claims per provider per quarter for compliance
- Educate teams on trends during RCM huddles or compliance briefings
Quick Win: Establish a 3-strike documentation policy—flagging providers with repeated Modifier 25 issues for retraining.
## 5. Appeal Denials with Strong Clinical Language
Why It Matters:
Not all denials are avoidable—but with clean documentation and correct usage, you can overturn many Modifier 25 denials.
Implementation Tips:
- Use appeal templates that explain CMS Modifier 25 criteria
- Reference distinct ICD-10 codes and specific findings tied to the E/M
- Include supporting articles or CMS guidance with your appeal packet
Quick Win: Use “Modifier 25 Appeal Kit” PDFs that front desk, coding, and billing staff can access for common scenarios.
📍 Case Study: Avoiding a $28K Loss from Modifier 25 Errors
A suburban dermatology group saw a sudden spike in denied claims for office visits—despite documenting full E/M services alongside cryotherapy and biopsies. After a Thrive Revenue Cycle audit, we found:
- Modifier 25 was being placed on procedure codes
- Providers didn’t clearly separate the E/M from the minor procedures
- CCI edits weren’t being checked prior to billing
After implementing training, system changes, and compliance workflows:
- Denials for Modifier 25 dropped by 83%
- Clean claim rate for E/M + procedure combinations rose to 94%
- The clinic recovered $28,000 in previously denied services within 60 days
Ready to Protect Your E/M Revenue?
At Thrive Revenue Cycle, we help providers avoid costly Modifier 25 denials with smart, CMS-aligned strategies that stick. From pre-bill edits to compliance training and appeal support—we turn complex guidelines into clean claims.
👉 Book your free Modifier 25 compliance audit today
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