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In the world of U.S. healthcare billing, Modifiers 25 and 59 continue to be two of the most misunderstood and misused codes, even as we move through 2025.
Year after year, industry organizations like the AAPC and American Medical Association (AMA), along with various billing and compliance experts, have pointed out ongoing issues with how these modifiers are applied.
In fact, the Office of Inspector General’s (OIG) Work Plan has repeatedly flagged them due to their high potential for billing errors, overuse, and even fraud.
Still, they remain among the most common reasons for claim denials, causing delays, lost revenue, compliance issues, and confusion among staff.
In this blog, we’ll break down why Modifiers 25 and 59 continue to be so problematic, explore how technology is helping address the issue, and share what clinics can do to finally use them correctly, with clarity, compliance, and confidence.
E/M codes and modifiers are two of the most commonly used code types. Although they often get lumped together, they serve very different purposes.
Evaluation and Management (E/M) codes describe the complexity and nature of a patient encounter. They are foundational to documenting and billing office visits and other face-to-face services.
They represent the time, decision-making, and complexity involved in the visit. Help classify encounters like new vs. established patients, or low vs. high complexity, and are always five-digit numeric codes.
For example, if a provider spends 30 minutes with a new patient managing multiple chronic conditions, the visit might be coded as 99204.
Modifiers, on the other hand, are two-character suffixes (letters or numbers) added to Current Procedural Terminology (CPT) or E/M codes to explain special circumstances. They provide critical context to the payer without changing the core meaning of the code. In other words, they are used to indicate that a procedure was modified, but is still valid and distinct.
For example, if a patient comes in for a scheduled checkup but also gets a knee injection, a coder may apply:
Without the modifier, the payer may deny the E/M portion, assuming the visit was only for the procedure.
Modifier 25 is added to an Evaluation and Management (E/M) code when a provider performs a significant, separately identifiable E/M service on the same day as a minor procedure (typically one with a 0- or 10-day global period). This means the E/M visit must involve clinical decision-making beyond what’s normally needed for the procedure.
For example, a patient comes in with a painful skin lesion. The provider evaluates the lesion, reviews the patient’s history, performs an exam, and decides to remove it. At the same visit, the patient also reports shortness of breath. The provider conducts an additional evaluation, orders a chest X-ray, and assesses for possible heart or lung issues.
In this case, the E/M service is separate and significant, and Modifier 25 is justified because the provider addressed an additional complaint unrelated to the procedure.
To elaborate, Modifier 25 is appropriate when:
However, not every situation involving an E/M and procedure on the same day warrants Modifier 25, especially in these situations:
Insurance payers, including Medicare, monitor high use of Modifier 25 closely. If your practice frequently bills E/M codes with Modifier 25 on the same day as minor procedures, your claims may be flagged for review or denial. Clear documentation and clinical justification are your best defense.
Modifier 59, on the contrary, is used to identify procedures or services that are not normally reported together but are appropriate under the circumstances due to differences in:
For example, a physical therapist provides therapeutic activities to both the right shoulder and left knee. These involve different muscle groups, different goals, and different time segments. Modifier 59 supports that the therapist is performing distinct procedures in terms of anatomy and documentation.
This distinction is essential because it ensures accurate reporting and reimbursement for services that are genuinely separate. Modifier 59 helps differentiate scenarios where services might otherwise appear bundled but are, in fact, independently performed.
By correctly applying this modifier, providers can demonstrate the medical necessity and uniqueness of each service. The Modifier 59 is most appropriate in:
However, despite its intended purpose, many claims are submitted with Modifier 59 without sufficient justification, putting providers at risk of audits or recoupment.
Modifier 59 should be used only when absolutely necessary and not as a go-to solution. It’s meant to explain why two procedures that normally aren’t billed together were actually separate and needed. The Office of Inspector General (OIG) keeps an eye on Modifier 59 misuse. Overusing it, especially without solid documentation, is one of the top reasons providers get audited.
And here’s the part that we don’t like talking much about.
It’s not a coding issue. It’s a communication issue. A workflow issue. A cultural issue. And below is how, if not fixed, it bleeds revenue every single day.
When modifiers are misused, or even just perceived as misused, the consequences create a ripple effect.
Until we shift from checkbox compliance to true interdisciplinary understanding, Modifiers 25 and 59 will keep doing damage in silence: one denial, one delayed payment, one audit at a time.
Advanced technology is now front and center in helping clinics master modifier use with precision, consistency, and compliance. Modern RCM platforms go beyond basic flagging:
Besides eliminating financial blockages, AI-driven technologies also enable deep visibility and benchmarking. In 2025, smart RCM systems include intuitive analytics dashboards that let clinics:
These insights help transform data into action. For example, clinics can set automated flags when Modifier 25 or 59 is applied without a corresponding diagnosis or distinct procedural note. In addition, it’s wise to audit 10 to 15 records per provider each quarter to uncover misuse patterns early and guide education.
Ultimately, mastering modifiers is a mix of awareness, documentation discipline, and tech-enabled workflows. When used effectively, AI and smart analytics turn Modifier 25 and 59 from common denial triggers into strategic tools for proper reimbursement and compliance.
From the Expert’s Desk: Dos and Don’ts for Modifier 25 and 59
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In most cases, the misuse of Modifiers 25 and 59 is more due to workflow problems. Healthcare entities must foster a culture of shared accountability between clinicians, coders, and billing teams.
Further, by investing in training, technology, and regular audits, clinics can reduce denials, improve reimbursements, and most importantly, build a practice that’s clinically sound and financially resilient.
The path to modifier mastery starts with discipline, tools, and documentation. Get those three right, and Modifier 25 and 59 will no longer be your revenue nightmares, but assets in your reimbursement toolkit.
