Modifier 25 in Medical Billing: When a Same-Day Visit Is Paid

Modifier 25 is the modifier you add to a visit code, such as 99214-25, to tell the payer that a visit on the same day as a procedure was a significant, separately identifiable service, above and beyond the normal care that comes with the procedure. Without it, the payer treats the visit as part of the procedure and pays nothing for it.

It is one of the most used modifiers there is, and one of the most argued about. Most of the arguments come down to the same question: was there really a second service?

Is the visit billable? At a glance

On the same day as the procedure, the physician…	Bill the visit?
Reviewed the chart, examined the site, explained the procedure and got consent	No. That is part of the procedure
Decided to do a minor procedure (0 or 10-day global) and did it	No. The decision is part of a minor procedure
Decided to do a major procedure (90-day global)	Yes, with modifier 57, not 25
Worked up a separate problem, or managed the condition beyond the procedure’s usual care	Yes, with modifier 25
Saw a new patient and did a minor procedure, nothing more	No. Being new is not enough
Saw the patient for a separate problem on a chemotherapy day	Yes, 99212 to 99215 with modifier 25; never 99211

Where you see it

Place	What goes there
CMS-1500 box 24D, 837P loop 2400 SV101	The visit code with modifier 25 (99214-25). The procedure code goes on its own line with no modifier 25
Box 21 and the diagnosis pointer in 24E	Point the visit at the problems the visit addressed. They can be the same as the procedure’s
The medical record	Two clearly separate pieces of documentation: the visit note and the procedure note
The remittance	A missing or unsupported modifier 25 shows up as a bundled visit, usually CARC 97 (paid as part of another service)

What Medicare allows

The rules are in the Medicare Claims Processing Manual, chapter 12, section 30.6.6, and in chapter I of the NCCI Policy Manual. In plain terms:

• It goes on visit codes only, and only when the same physician or practitioner does a procedure or other service for the same patient the same day.
• The visit must be above and beyond the usual pre- and post-procedure work. Checking the site, explaining the procedure and getting consent are part of the procedure.
• Different diagnoses are not required. The visit can address the same condition as the procedure, as long as the visit itself is a separate piece of work.
• The decision to do a minor procedure (0 or 10-day global) is part of the procedure, even for a new patient. The decision for a major procedure (90-day global) is billed with modifier 57. See the global surgical package.
• It also applies to services with no global period (XXX), such as drug administration and many tests, but the visit cannot include supervising or interpreting the test.
• Records are not sent with the claim, but must support it. A Medicare contractor can require them before paying a practice that uses modifier 25 far more than its peers.

In oncology and urology

Chemotherapy days. Drug and chemotherapy administration codes (96360 to 96379 and 96401 to 96425) are valued to include a 99211 visit, so 99211 is never billed with them. A higher-level visit with modifier 25 needs separate physician work, for example evaluating new neuropathy and changing the regimen. See chemotherapy administration codes.

Cystoscopy. 52000 has a 0-day global period, so a same-day visit needs modifier 25 and work beyond the scope. See billing urology in-office procedures.

Dialysis. Visits related to the dialysis or to the renal failure are included in the dialysis codes. A visit for an unrelated problem can be billed with modifier 25 only when it could not be done during the dialysis session.

Worked example: a surveillance cystoscopy

An established patient with a history of bladder cancer comes in for a scheduled surveillance cystoscopy. The scope is clear. The patient also describes two weeks of new flank pain; the urologist takes a history, examines the patient, orders a CT and starts treatment for a likely kidney stone. Figures are 2026 national non-facility amounts, before geographic adjustment, from the CMS RVU file (conversion factor 33.4009).

Line	Code	Total RVUs	Amount
Cystoscopy	52000	6.46	215.77
Visit for the flank pain	99215-25	5.76	192.39

The flank pain workup is a separate problem with its own history, exam and decisions, so the visit gets modifier 25. The level depends on what the note supports; with less documented decision making it could be 99214. Had the visit covered only the review and consent, the practice would bill 52000 alone. Without the modifier, the visit is denied as bundled (CARC 97).

The 2027 rule

From January 1, 2027, Medicare pays less when an office or outpatient visit is billed by the same physician, or a physician in the same practice, on the same day as a procedure with a 0-day global period. The higher-paid service is paid in full and the other at 80 percent. CMS had proposed 50 percent and had included 10 and 90-day global procedures; the final rule, released November 4, 2026, dropped both. Applied to the example above, with 2027 amounts from the final rule (conversion factor 32.63):

Line	2026	2027 final
52000 cystoscopy	215.77	202.63 (the higher-paid service, paid in full)
99215-25 visit	192.39	146.70 (183.38 at 80 percent)

• Only 0-day globals count. Cystoscopy (52000) is reduced; a visit with a 10 or 90-day global procedure is not.
• Codes with no global period are not affected. Drug administration is XXX, so a visit with chemotherapy administration is paid in full.
• Do not move visits to another day to avoid it. CMS said in the proposed rule that it would watch for that.

See the 2027 Medicare final rules for radiation oncology.

Other payers

Commercial and Medicare Advantage plans can write their own modifier 25 rules. In 2023 Cigna announced it would require office notes with every claim billing 99212 to 99215 with modifier 25 and a minor procedure, then delayed it after the AMA and more than 100 other groups objected. When a plan denies a visit Medicare would pay, ask for the policy it applied.

What to do

• Check every same-day visit and procedure pair at charge entry. Ask one question: what did the physician do that was not part of the procedure?
• Keep the notes separate. A visit note with its own history, exam and decisions is the best support; one combined note is hard to defend.
• Never add modifier 25 just to get paid. In 2005 the HHS Office of Inspector General found that 35 percent of the modifier 25 claims Medicare allowed in 2002 did not meet the rules, about 538 million dollars in improper payments.
• Do not put modifier 25 on a visit when nothing else was billed that day. It is not needed, and the OIG counted it as improper use.
• Denials to recognize: CARC 97, the visit was paid as part of the procedure. If the record supports a separate service, correct the claim with modifier 25; otherwise it is not billable. CARC 4, the modifier does not fit the code, often modifier 25 on a procedure code. See claim adjustment group and reason codes.
• Iridium Suite’s claim scrubber warns at charge entry when a visit and a procedure share a date, so the biller confirms whether modifier 25 belongs on the visit before the claim goes out.

Related terms

• The global surgical package
• Chemotherapy administration codes 96413 to 96417
• Billing urology in-office procedures
• ESRD monthly capitation payment
• Radiation oncology modifiers
• Claim adjustment group and reason codes

Further reading: Medicare Claims Processing Manual, chapter 12, section 30.6.6; NCCI Policy Manual for Medicare Services, 2026, chapter I and chapter XI; CMS MLN booklet MLN907166, Global Surgery; CY 2027 physician fee schedule proposed rule, Federal Register; CMS fact sheet, CY 2027 physician fee schedule final rule; HHS OIG, Use of Modifier 25 (OEI-07-03-00470); AMA on Cigna’s modifier 25 policy; CMS PFS relative value files.