Modifier 25: when a same-day office visit stands apart from a procedure
For Medicare, the decision to perform a minor procedure is already paid for. Here is how to tell whether the office visit is separately reportable.
Can you bill an office visit on the day you perform a minor procedure? Under Medicare's 2026 NCCI policy, the decision to perform that procedure is included in its payment. A separate evaluation and management (E/M) service needs significant work, identifiable apart from that decision and the procedure's usual work. If the record supports it, append modifier 25 to the E/M code, not the procedure code.
The distinction is about work performed, not the number of problems on the encounter or whether the patient is new.
The decision to perform a minor procedure is included
For procedures with a 000- or 010-day global period, Medicare includes the decision to perform the minor procedure in the procedure payment. The usual pre- and postoperative work is included too. A new-patient visit does not change that rule.
Ask a narrower question before adding an E/M charge: what medically necessary evaluation and management happened besides deciding on and performing the procedure? The note should make that work identifiable. A second diagnosis is not required; CMS explicitly allows the E/M and procedure to relate to the same diagnosis. The service still has to be significant and separately identifiable.
Match the modifier to the work, not the claim edit
This table translates the 2026 Medicare NCCI manual's global-surgery and modifier rules into a chart-review question. It is for Medicare billing; check other payers' policies separately.
| Same-day situation | What the Medicare rule says | What to verify in the chart |
|---|---|---|
| Minor procedure with a 000- or 010-day global period | The decision to perform it and usual procedure work are included. Modifier 25 can identify a significant, separately identifiable E/M service beyond that decision. | Can the reader identify the additional E/M work without counting the procedure's inherent work again? |
| Procedure with global indicator XXX | Inherent pre-, intra-, and post-procedure work is not separately billable as E/M. A significant E/M above that work may qualify for modifier 25. | Is the E/M distinct from supervising the procedure or interpreting its result? |
| Major procedure with a 090-day global period | A same-day E/M to decide whether to perform major surgery may be separately reported with modifier 57, not 25 for that decision. Other preoperative E/M work is included. | Is this a decision for major surgery rather than a separate minor-procedure visit? |
CMS also says not to append a modifier merely to bypass an NCCI procedure-to-procedure edit. The clinical circumstances must justify it. That is why a claim edit or a prompt in billing software cannot establish the modifier by itself.
Review the note before submitting the claim
Keep the procedure's inherent work out of the separately billed E/M. Identify what was evaluated, what management was provided, and why that service stands apart. Then confirm the procedure's global indicator and apply the relevant Medicare rule. If the documentation only describes the decision and the procedure, do not add an office visit simply because both happened on the same date.
Source: CMS, Medicare NCCI 2026 Coding Policy Manual, Chapter 1, pages I-12–I-15, revised January 1, 2026.