Modifier 25 Is Not Optional. Neither Is the Documentation.

Why removing a modifier while retaining the E/M service creates unnecessary revenue and compliance risks

There are certain coding decisions that require professional judgment, interpretation, and careful consideration of the documentation.

And then there are situations where the rules are already clear.

Modifier 25 is one of them.

I continue to see confusion surrounding the reporting of evaluation and management (E/M) services performed on the same day as minor procedures. More specifically, situations where an E/M service remains on the claim, but modifier 25 has been removed.

That is not necessarily conservative coding. It may simply be incorrect coding.

When a significant, separately identifiable E/M service is performed by the same physician or other qualified healthcare professional on the same date as a qualifying procedure, modifier 25 is necessary to distinguish that service from the work ordinarily included in the procedure.

The real question is not whether we want to use modifier 25.

The question is whether the documentation supports reporting a separate E/M service in the first place.

Let’s Talk About a Common Example

Consider CPT 20610, which represents arthrocentesis, aspiration, and/or injection of a major joint or bursa without ultrasound guidance.

A patient presents for a knee injection.

The physician evaluates the treatment area, confirms the planned procedure is appropriate, discusses the injection, obtains consent, and performs the service.

Does that automatically support a separate E/M?

No.

Those activities may fall within the routine work associated with the procedure.

Now consider a different scenario.

The patient presents with worsening symptoms, and the physician performs a medically necessary evaluation that extends beyond the usual work associated with the injection. The physician assesses additional clinical concerns, evaluates treatment alternatives, and develops a management plan that goes beyond the decision to perform the injection.

Depending on the documented work and medical necessity, a separate E/M service may be supported.

When that E/M service meets the applicable reporting requirements, modifier 25 belongs on the E/M code.

For example:

• 20610 — Joint injection
• 99213-25 — Separately supported E/M service, when the documented work meets the requirements for that level

The modifier is appended to the E/M service, not the procedure.

It is also important to remember that CPT does not require different diagnoses to support modifier 25. The additional E/M may involve the same condition, provided the work is significant, separately identifiable, and exceeds what is ordinarily included in the procedure.

These principles are supported by AMA CPT guidance and the 2026 Medicare NCCI Policy Manual.

Removing the Modifier Does Not Resolve the Coding Question

This is where I think coding teams sometimes complicate a relatively straightforward decision.

If you believe the E/M service is not separately reportable, evaluate the documentation and determine whether the E/M should remain on the claim.

If the E/M is supported, retain it and report the appropriate modifier.

But removing modifier 25 while leaving the E/M service on the claim does not address whether the service was separately performed.

Instead, it can create another problem.

The claim may be subjected to bundling edits, resulting in a denial or payment delay.

And there is another consideration that deserves attention.

A claim being paid does not automatically mean it was coded correctly.

HHS-OIG Is Looking at This Exact Issue

This is not simply a theoretical concern.

On March 16, 2026, the Department of Health and Human Services Office of Inspector General announced a Work Plan review focused on E/M services billed on the same day as minor surgical procedures without modifier 25.

The OIG identified Medicare claims from calendar years 2023 through 2025 in which E/M services were processed and paid without modifier 25, despite being reported on the same date as minor surgery.

The review will examine whether Medicare Administrative Contractors processed and paid those claims in accordance with Medicare requirements.

That distinction is important.

We often focus on modifiers because they affect reimbursement. However, this review highlights something broader: payment processing does not eliminate the need for accurate coding and compliance with applicable billing requirements.

The OIG review remains listed as active, and its findings should not be presumed before the review is completed. Nevertheless, the subject of the review reinforces why organizations should understand and consistently apply modifier requirements.

Documentation Comes First. The Modifier Follows.

I have always believed coding should follow the documentation, not the other way around.

We should not be adding modifier 25 simply because a procedure and E/M occurred on the same day.

We also should not remove it simply because someone believes the payer may question the additional E/M.

Neither approach represents sound coding practice.

The expectation should be consistent:

If the E/M is separately supported and reportable: Retain the E/M and append modifier 25 when required.

Remember that modifier 25 is not a substitute for documentation. It does not make an otherwise bundled E/M service separately billable.

Likewise, removing the modifier does not change the clinical services performed or the documentation supporting them.

These are two different decisions, and coding teams need to understand the distinction.

This Is a Revenue Integrity Issue, Too

We frequently discuss modifier 25 in the context of compliance and audit risk. Those are certainly important considerations.

But I also want coding and billing professionals to recognize the operational impact.

An incorrectly omitted modifier can contribute to unnecessary denials, additional accounts receivable follow-up, appeals, and delayed reimbursement.

An incorrectly appended modifier can create a different problem: unsupported separate reimbursement and potential overpayment exposure.

Both situations consume resources that healthcare organizations cannot afford to waste.

And both are preventable when coding teams have clear expectations, appropriate education, and reliable escalation processes.

Revenue integrity is not about maximizing reimbursement at every opportunity.

It is about ensuring that the organization accurately reports the services performed, receives the reimbursement it has legitimately earned, and can defend the claim when questioned.

My Final Thought

Coding requires judgment. I understand that, and after more than two decades in this industry, I know that not every encounter fits neatly into a simple example.

But we cannot allow professional judgment to become inconsistent application of established reporting requirements.

Modifier 25 is not optional when the circumstances require it.

What requires judgment is determining whether the E/M service is significant, separately identifiable, medically necessary, and supported by the documentation.

Once that determination has been made, the coding should accurately reflect it.

If your team is routinely removing modifier 25 while leaving separately reportable E/M services on claims, I would encourage you to evaluate that workflow.

Because sometimes the problem is not the documentation, the payer, or even the code selection.

Sometimes it is a small decision in the coding process that creates an entirely avoidable problem.

And those are exactly the kinds of problems we should be working to eliminate.

Healthcare Inspired
Clear documentation. Defensible coding. Stronger revenue integrity.