Supplemental Billing Information - Appropriate Use of Modifiers 25 and 59

Oct 6, 2026

Uploaded by Connor

Supplemental billing guidance defining how to apply CPT modifiers 25 and 59. Modifier 25 is described as a separately identifiable, significant evaluation and management service by the same clinician on the same day, with clear documentation requirements in a distinct medical record section. Modifier 59 is defined as a distinct procedural service for non-E&M procedures, supported by evidence of a different session, encounter, site, lesion, or separately performed service. Educational note emphasizes provider responsibility and directs readers to NCCI materials and CMS resources.

LanguageEnglish

CategoryHealthcare

FormatPDF

Pages2

Reading Time5 min

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Supplemental Billing Information

General Guidelines for Modifier 25

General Guidelines for Modifier 59

Important Note and References

Supplemental Billing Information: Appropriate Use of Modifiers 25 and 59 The Current Procedural Terminology (CPT) defines modifier 25 as a “significant, separately identifiable evaluation and management service by the same physician or other qualified health care professional on the same day of the procedure or other service.” General Guidelines for Modifier 25 from the CPT: 􀁸 Modifier 25 may be appended only to Evaluation and Management (E&M) codes within the range of 92002 – 92014 and 99201 – 99499. 􀁸 To appropriately append modifier 25 to an E&M code, the provided service must meet the definition of “significant, separately identifiable E&M service” as defined by CPT. 􀁸 When appending modifier 25 to an E&M service billed on the same date of service as a procedure or other service, documentation for the additional E&M must be entered in a separate section of the medical record in order to validate the separate and distinct nature of the E&M service. The additional E&M service must be able to stand alone as a billable service with no overlapping of key E&M components (e.g., medical history, medical examination, and medical decisionmaking performed) . The CPT defines modifier 59 as a “distinct procedural service.” General Guidelines for Modifier 59 from the CPT: 􀁸 Modifier 59 is used to identify procedures/services, other than E&M services, that are not normally reported together, but are appropriate under the circumstances. o Modifier 59 should not be appended to an E&M code. To report a separate and distinct E&M service with a non-E&M service performed on the same date, see modifier 25. 􀁸 When appending modifier 59, documentation must support that the procedure/service represents a different session or patient encounter, procedure or surgery, anatomic site or organ system, lesion (through a separate performed incision/excision or for a separate injury or area of extensive injuries), or procedure not typically performed on the same day by the same individual. 􀁸 Modifier 59 should only be reported if a more descriptive modifier (e.g., modifier XE, XP, XS, or XU) is unavailable, and it is the most accurate modifier that is available to describe the circumstances. Important Note: This information is for educational purposes only. It is ultimately up to the provider to determine what to bill based on the services furnished. It is recommended that providers and other interested parties refer to the National Correct Coding Initiative (NCCI) Policy Manual for Medicaid Services (NCCI Policy Manual) and the Modifier 59 article (Modifier 59 Article) for detailed information regarding appropriate modifier usage, which can be found on the [CMS Medicaid.gov](CMS Medicaid.gov) website.

FAQs

What is modifier 25 under CPT, and when can it be appended?

Modifier 25 is a significant, separately identifiable evaluation and management service by the same clinician on the same day. It may be appended only to E&M codes in the specified CPT ranges when documentation supports the service definition.

How should documentation be handled when using modifier 25 on the same date as another service?

The additional E&M documentation must be entered in a separate section of the medical record to validate the service’s separate and distinct nature, with no overlapping key E&M components such as medical history, exam, or decision-making.

When should modifier 59 be used, and what must documentation show?

Modifier 59 identifies procedures/services (non-E&M) not normally reported together but appropriate under the circumstances. Documentation must support a different session or patient encounter, procedure or surgery, anatomic site or organ system, lesion (via separate performed incision/excision or separate injury area), or a procedure not typically performed the same day by the same individual.

Oct 6, 2026

Uploaded by Connor