CPT Modifiers 24 and 25: Mastering E/M Billing for Practices

For practice managers, healthcare providers, and owners, mastering CPT Modifiers 24 and 25 is essential. These modifiers prevent payment bundling, ensure accurate distinction of services, and protect your practice’s revenue cycle. Failure to use them correctly results in denied or reduced claims.

What Is Modifier 24, and When Should It Be Used?

Modifier ¹$\mathbf{24}$ is used when a provider sees a patient during the post-operative period but treats a new, unrelated condition.² This modifier signals to the payer that the Evaluation and Management (E/M) service performed is not part of the standard global surgical package.

• Example: A patient returns for a post-op follow-up after knee surgery. However, they also complain of a new, acute headache. If the provider evaluates and manages this unrelated headache, modifier $\mathbf{24}$ should be added to the E/M code for that visit.
• Why it matters: Modifier $\mathbf{24}$ ensures providers receive proper reimbursement for addressing new, unexpected issues during a follow-up visit. Therefore, it prevents the E/M service from being incorrectly bundled into the prior surgical payment.

What Is Modifier 25, and When Should It Be Used?

Modifier ³$\mathbf{25}$ applies when a provider performs a significant, separately identifiable E/M service on the same day as a procedure.⁴ This E/M service must go above and beyond the usual pre- and post-operative work already included in the procedure’s payment.

• Example: A patient presents with acute chest pain. The physician conducts a thorough E/M evaluation, assesses the patient’s history, and determines that an immediate stress test is necessary. Furthermore, the physician performs the stress test on the same day. Modifier $\mathbf{25}$ should be added to the E/M code for the chest pain evaluation.
• Why it matters: This modifier ensures that the initial, often complex, decision-making process—which led to the procedure—is recognized and reimbursed separately. Consequently, it distinguishes the E/M service from what is typically included in the procedural work’s global fee.

Conclusion

Mastering CPT Modifiers 24 and 25 is mandatory for minimizing claim denials and accurately capturing physician work. In summary, using these modifiers correctly prevents claim bundling and protects revenue integrity.