What is modifier 25 and 27?


Editorial team Published on

Modifier 25 and Modifier 27 are both medical billing codes used for Evaluation and Management (E/M) services on the same day, but they apply to entirely different clinical scenarios and billing contexts.

Modifier 25

  • Definition: A significant, separately identifiable E/M service performed by the same physician on the same day as a procedure or other service.
  • Purpose: Indicates that the provider's work for the E/M went "above and beyond" the usual pre-operative or post-operative care tied to a minor procedure done that same day.
  • Setting: Commonly used in office, clinic, and professional outpatient settings.
  • Example: A patient visits for knee pain evaluation, and the doctor performs both an E/M service and an unrelated joint injection during that single visit. You append Modifier 25 to the E/M code.
  • Guidelines: Learn more about proper criteria through the American Medical Association.

Modifier 27

  • Definition: Multiple outpatient hospital E/M encounters on the same date for the same patient.
  • Purpose: Appended to the second and subsequent E/M codes to show a separate, distinct encounter from an earlier visit that same day in a hospital setting.
  • Setting: Exclusive to hospital outpatient departments, clinics, or emergency departments; prohibited for regular physician/private practice professional claims (CMS-1500). It is used on facility claims (UB-04).
  • Example: A patient goes to the emergency department in the morning for a sprained wrist and returns later that same evening for an unrelated acute asthma flare-up.
  • Guidelines: Review details on hospital billing rules via the Centers for Medicare & Medicaid Services.