When To Use Modifier 24 Vs Modifier 25: Examples And Billing Guidelines

By Author: Charlie Robinson
Total Articles: 49
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In the realm of medical billing, even a small coding mistake can lead to denied claims, delayed reimbursements, or an increased likelihood of audits. One of the most frequent issues arises from the incorrect use of modifiers—especially Modifiers 24 and 25. These modifiers play a vital role in accurately reporting evaluation and management (E/M) services provided alongside surgical procedures. However, they are often misinterpreted or improperly applied. Such errors can result in claim rejections, compliance concerns, and financial setbacks for healthcare practices.
This blog offers a comprehensive overview of how to correctly use Modifiers 24 and 25, along with essential medical billing and coding guidelines every provider should know.
Modifier Overview:
Modifier 24 is applied when a patient receives an evaluation and management (E/M) service during the global period of a previous surgery, but for a condition that is completely unrelated to that surgical procedure. This modifier is exclusive to E/M codes and signifies that the visit is not part of the routine post-operative care or complications arising from ...
... the surgery. It is frequently used in specialties such as surgery, ophthalmology, and optometry. To apply Modifier 24 correctly, the provider must clearly document a different diagnosis and explain why the service is unrelated to the prior procedure.
Modifier 25 is used when a healthcare provider delivers a significant and separately identifiable E/M service on the same day as another procedure. This is applicable when the evaluation addresses additional concerns beyond the usual care associated with the procedure. Modifier 25 is commonly used in primary care, dermatology, emergency medicine, and other similar fields. Accurate use of this modifier requires that the service is medically necessary, clearly documented as distinct, and justified, even if it involves the same diagnosis as the procedure.

When to Apply Modifier 24:
• Assessment for a New, Unrelated Issue
Modifier 24 is appropriate when a patient is in the global post-operative period but returns with a health concern that is completely unrelated to the initial surgery.
Example: A patient who recently underwent hernia surgery comes back within the 90-day global period due to a urinary tract infection. Since the condition is unrelated to the surgical procedure, Modifier 24 should be reported.
• New Symptoms in a Different Area of the Body
Use Modifier 24 if the patient presents with symptoms affecting a body region that was not involved in the surgical procedure.
Example: A patient who had cataract surgery two weeks ago now complains of shoulder pain. As the complaint is unrelated to the eye surgery, Modifier 24 is justified.
• Condition Involving the Opposite Organ or Side
This modifier is also applicable when care is provided for a condition that affects the same system but occurs on the opposite side or a different, unrelated area.
Example: If a patient had surgery on the left eye and later develops a new issue in the right eye, Modifier 24 is appropriate because the two issues are separate.
• Unrelated Co-Management Evaluations
If a provider who is co-managing a post-operative patient’s care also evaluates a separate, unrelated issue, Modifier 24 must be used.
Example: An optometrist managing a patient’s cataract recovery examines the other eye for a different vision concern. Since this issue is unrelated to the surgical procedure, the use of Modifier 24 is correct.
• Ongoing Care for an Unrelated Chronic Condition
Modifier 24 should be used if the patient is being seen for routine management of a chronic condition that is unrelated to the recent surgery.
Example: A patient recovering from gallbladder surgery comes in for regular diabetes follow-up. As this care is not associated with the surgery, Modifier 24 is appropriate.
When to Apply Modifier 25:
• Evaluation That Results in a Procedure
Modifier 25 should be appended when a provider performs an evaluation and management (E/M) service to assess a patient’s complaint, which then leads to a medically necessary procedure during the same visit.
Example: A patient experiencing sinus discomfort undergoes a full evaluation, and based on the findings, the provider performs a nasal endoscopy.
• New Concern Raised During a Planned Procedure Visit
Apply Modifier 25 if a patient arrives for a scheduled procedure but also mentions a separate issue that needs to be evaluated independently.
Example: A patient comes in for wart removal but also complains of stomach pain. The provider conducts a separate evaluation for the abdominal concern. Modifier 25 is applicable here.
• New Problem Identified During a Preventive Exam
If a preventive check-up leads to the discovery of a new medical issue that warrants its own diagnostic workup, Modifier 25 should be used for the problem-focused E/M service.
Example: A patient undergoing a routine wellness visit reports shortness of breath. The provider conducts additional evaluation, making Modifier 25 appropriate.
• Urgent or Emergency Visit with an Added Procedure
In cases where both a significant evaluation and a medically necessary procedure are performed during a walk-in or emergency visit, Modifier 25 should be reported.
Example: A patient presents with lower back pain that radiates to the legs. After assessing the condition, the provider gives an intramuscular injection. If the procedure qualifies under status indicators (S, T, Q1–Q3), Modifier 25 must be used with the E/M code.
• Separate Conditions Managed in One Visit
Use Modifier 25 when the provider treats a condition different from the reason for the scheduled procedure.
Example: A patient is seen for urinary symptoms but also has a skin lesion removed during the same visit. If each service is properly documented and individually addressed, Modifier 25 is appropriate.
Billing Guidelines:
Modifier 24:
• Modifier 24 is only applicable to Evaluation and Management (E/M) codes and should not be used with surgical or procedural codes, no matter the circumstance.
• If a provider from the same group and specialty sees the patient during the global period, Modifier 24 is still valid, since many insurers, including Medicare, consider these providers as one and the same for billing purposes.
• Documentation must clearly demonstrate that the visit is for a completely unrelated issue to the original surgery. The notes should include the patient's symptoms, diagnosis, and a treatment plan specific to the new condition.
• Do not use Modifier 24 for follow-ups related to surgical complications or routine post-operative care, such as wound checks, expected pain, or infections. These services fall under the global surgical package.
Modifier 25:
• For Modifier 25 to be reimbursed separately under Medicare, the procedure performed during the same visit must have a status indicator of S, T, or Q1–Q3. If the indicator is N (packaged), the E/M service cannot be billed separately.
• Even when an E/M service is justified, poor documentation may lead to claim denials or audits. Ensure your notes clearly outline the separate findings, assessments, and clinical decisions that support the additional service.
• If a new issue is addressed during a preventive check-up, apply Modifier 25 only to the problem-oriented E/M code, not the preventive code itself.
• Excessive or improper use of Modifier 25, especially without robust documentation, may result in payer audits or allegations of upcoding. Use it only when medically necessary and well-documented.
• Modifier 25 can be applied when E/M services are performed alongside both simple and complex procedures, as long as the E/M effort goes beyond what is typically included in the procedure.
Conclusion:

While it may seem challenging at first, properly applying Modifiers 24 and 25 in E/M Coding can becomes much easier with a good understanding of the global period and coding rules. Correct use helps ensure appropriate reimbursement, reduces claim denials, and protects against compliance issues. Avoid common pitfalls, such as using both modifiers together or pairing them with unrelated ones.
To reduce errors and boost billing efficiency, it’s essential to work with trained and up-to-date coders. A smart approach is to outsource your billing and coding tasks to professionals like 24/7 Medical Billing Services. Our certified experts stay current with the latest changes in the industry.
Call us today at +1 888-502-0537 or email us at sales@247medicalbillingservices.com to learn how we can streamline your practice’s billing process.

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