When to Use Modifier 24 vs Modifier 25: Examples and Billing Guidelines

In medical billing, even a minor coding error can result in claim denials, delayed payments, or increased audit risks. One of the most common mistakes occurs when modifiers are misapplied, particularly Modifier 24 and Modifier 25. Although these modifiers are essential for reporting evaluation and management (E/M) services in conjunction with surgical procedures, they are frequently misused or misunderstood. The improper use of these modifier combinations can lead to invalid claims, compliance problems, and financial losses for healthcare providers.

This blog will serve as a complete guide to understanding the proper application of Modifiers 24 and 25 and key billing guidelines.

Overview of Modifiers:

Modifier 24 is used when a patient receives an evaluation and management (E/M) service during the global period of a previous surgery, but for a condition entirely unrelated to that surgery. It applies only to E/M codes and helps indicate that the visit was not part of the routine post-operative care or surgical complications. It is commonly used in specialities like surgery, ophthalmology, and optometry. Additionally, the proper use of Modifier 24 requires clear documentation of a separate diagnosis and justification for why the service falls outside the scope of the original procedure.

Modifier 25 is used when a provider performs a significant, separately identifiable evaluation and management (E/M) service on the same day as a procedure. It applies when the evaluation goes beyond the usual pre- or post-procedure care and addresses additional or unexpected issues. This modifier is widely used in primary care, emergency medicine, dermatology, and similar specialities. Moreover, the proper use of Modifier 25 requires that the service be medically necessary, distinctly documented, and justifiable, even if it shares the same diagnosis as the procedure performed.

When to Use:

Modifier 24:

• Evaluation for a New and Unrelated Condition

Use Modifier 24 when a patient is in the post-operative global period of a procedure and returns for evaluation of a health issue that is entirely unrelated to the surgery or its recovery. Example: A patient who had hernia repair returns within the 90-day global period with a urinary tract infection. Since the UTI is unrelated to the hernia procedure, Modifier 24 is appropriate.

• New Symptoms in a Different Body Area

Apply Modifier 24 if the patient presents with symptoms in a body part that was not involved in the surgery. Example: A patient who had cataract surgery two weeks ago returns complaining of shoulder pain. The shoulder issue is new and not linked to the eye procedure, so Modifier 24 applies.

• Condition Affecting the Non-Operated Organ or Side

Use Modifier 24 when a provider treats a problem in the same general system but on the opposite side or in an unrelated area. Example: A patient underwent surgery on the left eye and later presents with a new issue in the right eye. Since the condition is in the non-operated eye, Modifier 24 is appropriate.

• Co-Management Services for an Unrelated Issue

When a provider involved in co-managing care evaluates an unrelated condition during the global period, Modifier 24 is used. Example: An optometrist managing post-operative cataract care evaluates a patient for a new vision problem in the other eye. If the issue is unrelated to the original surgery, Modifier 24 should be used.

• Follow-Up for Preexisting Chronic Condition

Use Modifier 24 if the patient receives routine management of a preexisting chronic condition that has no relation to the surgery performed. Example: A patient recovering from gallbladder surgery visits for routine diabetes management.

Modifier 25:

• Separate Evaluation Leading to a Procedure

Use Modifier 25 when an E/M service is performed to evaluate a complaint, and the provider decides to perform a procedure based on that evaluation during the same visit. Example: A patient with sinus pain undergoes a complete exam, and the provider performs a nasal endoscopy.

• Additional Complaint During a Scheduled Procedure Visit

Apply Modifier 25 when the patient is scheduled for a procedure but also brings up a new concern that requires a separate evaluation. Example: A patient scheduled for wart removal also reports stomach pain, which the provider evaluates.

• Problem Identified During Preventive Visit

Use Modifier 25 when a new medical issue is addressed during a preventive exam and requires a separate workup. Example: A patient undergoing a routine check-up mentions shortness of breath. The provider investigates the issue separately. Modifier 25 should be used for the problem-oriented E/M service.

• Emergency or Walk-In Visit with Additional Procedure

Use Modifier 25 when the provider performs both a significant evaluation and a procedure during an urgent visit, and both services are medically necessary. Example: A patient presents to the ER with lower back pain radiating down the legs. After evaluation, the provider administers an intramuscular injection. If the procedure has a qualifying status indicator (S, T, Q1–Q3), Modifier 25 is used with the E/M code.

• Evaluation and Treatment for Separate Diagnoses

Modifier 25 is used when the provider evaluates a second diagnosis during the visit that is distinct from the procedure's purpose. Example: A patient presenting with urinary symptoms is also treated for the removal of an unrelated skin lesion. If both are documented and separately managed, Modifier 25 is appropriate.

Billing Guidelines:

Modifier 24:

• Modifier 24 should be applied exclusively to Evaluation and Management (E/M) codes. It is not valid for surgical or procedural codes, regardless of the clinical scenario.
• If any provider in the same group and speciality sees the patient during the global period, Modifier 24 still applies, since Medicare and many payers treat providers within the same speciality and group as the same physician.
• The provider’s note must clearly explain how the visit relates to an issue entirely separate from the initial surgery. This includes specific symptoms, diagnosis, and care plan tied to the unrelated condition.
• Do not append Modifier 24 when the visit is for complications or expected post-op issues (e.g., infections, wound checks, pain at the surgical site). These are considered part of the global surgical package.

Modifier 25:

• The status indicator of the procedure must be S, T, or Q1–Q3 to allow for separate payment of the E/M service on Medicare claims. If the status indicator is N (packaged), you cannot bill the E/M service separately, even if it was provided.
• Even when the E/M service is medically necessary, insufficient documentation can lead to denials or audit flags. Always include distinct findings, assessments, and decision-making to justify separate billing.
• When a problem is addressed during a routine preventive visit, Modifier 25 should be added only to the problem-oriented evaluation and management (E/M) code, not the preventive visit code.
• Using Modifier 25 too frequently, especially without strong documentation, can trigger payer audits or accusations of upcoding. One should use it only when there is clear justification and medical necessity.
• Modifier 25 is appropriate for E/M services associated with both minor and complex procedures, provided the E/M work exceeds what is typically included in the procedure.

Conclusion

Though using Modifiers 24 and 25 in E/M coding can initially seem complex, understanding the global period and applying the correct guidelines can significantly simplify the process. Accurate use of these modifiers not only ensures proper reimbursement but also protects providers from claim denials and compliance risks. It is essential to avoid common mistakes, including incorrect combinations, such as using Modifier 24 and 25 together or mixing them with unrelated modifiers.

To minimise errors and improve billing accuracy, it is crucial to have well-trained and updated coding professionals. A reliable solution is to outsource medical billing and coding services to 24/7 Medical Billing Services. Our certified coders are continually trained to stay aligned with the latest medical coding and billing guidelines.

To learn more about how we can support your practice, call us at +1 888-502-0537 or email us at sales@247medicalbillingservices.com.

FAQs

Q1. Can Modifier 24 and 25 be used together on the same claim?

They serve different purposes and should not be reported together for the same evaluation and management (E/M) service.

Q2. Can Modifier 24 be used for diagnostic testing?

Modifier 24 is valid only with Evaluation and Management (E/M) codes, not with diagnostic or procedural codes.

Q3. Does Modifier 25 apply to telehealth visits?

If the E/M is distinct and separately identifiable from the telehealth procedure.

Q4. Does the type of insurance affect the usage of Modifier 24 or 25?

Commercial payers may have different policies from Medicare, so it is essential to verify guidelines.