Can Modifier 25 and 27 Be Used Together?

Medical coding and billing use a complex language to communicate healthcare services for accurate reimbursement. Modifiers provide additional details about a procedure or service without changing its fundamental definition. They clarify specific circumstances, such as when a service was altered or performed under unique conditions. This article demystifies the applications of CPT® modifiers 25 and 27, especially when their combined use might be appropriate.

Understanding Modifier 25

CPT® modifier 25, “Significant, Separately Identifiable Evaluation and Management Service by the Same Physician or Other Qualified Health Care Professional on the Same Day of a Procedure or Other Service,” indicates an Evaluation and Management (E/M) service was necessary beyond the usual pre- or post-operative care for a procedure on the same day. This modifier is appended to the E/M code to signify the E/M service was distinct and medically necessary. Its purpose is to allow separate reporting and potential reimbursement for both the E/M service and the procedure.

For instance, if a patient visits a physician for a new symptom requiring a comprehensive E/M service, and the physician performs a minor surgical procedure during that visit, modifier 25 would be appropriate. The E/M service must be significant and separately identifiable, meaning it could stand alone as a billable service. Different diagnoses are not always required for the E/M service and the procedure to use modifier 25, as the E/M might be prompted by the same condition. However, the E/M service must exceed the typical work included in the procedure’s global package.

Understanding Modifier 27

CPT® modifier 27, “Multiple Outpatient Hospital E/M Encounters on the Same Date,” is primarily for facility billing. Outpatient hospital departments, like emergency departments or clinics, use this modifier to report multiple, distinct E/M encounters for the same patient on the same calendar date. It signifies separate encounters, even if performed by different physicians or departments, or for unrelated problems.

Modifier 27 is designed for institutional claims, typically submitted on a UB-04 form, and is not generally used by professional (physician) billers on a CMS-1500 form. For example, a patient might present to the emergency department for one issue and later that day have a scheduled clinic visit in another hospital department for an unrelated condition. In such cases, modifier 27 is appended to the second and subsequent E/M codes to indicate distinctness. When reporting modifier 27, it is often accompanied by condition code G0, particularly when multiple medical visits occur on the same day within the same revenue centers.

Applying Modifiers 25 and 27 Together

While modifier 25 applies to professional services and modifier 27 to facility services, rare scenarios exist where both modifiers are relevant for a single patient on the same day. This situation arises when a patient receives multiple distinct E/M services in an outpatient hospital setting, and a physician performs a minor procedure during one of those E/M services. In such an instance, the hospital (facility) uses modifier 27 for multiple E/M encounters, and the physician uses modifier 25 for their professional E/M service alongside a procedure.

For example, a patient might have an initial E/M encounter in the emergency department, followed by a separate E/M service in an outpatient clinic where a minor procedure is performed. The hospital reports distinct E/M encounters using modifier 27, while the physician reports their E/M service with modifier 25 because it was significant and separately identifiable from the procedure. Proper application requires careful consideration of whether each service truly represents a distinct encounter or a significant, separately identifiable E/M.

Supporting Combined Modifier Use with Documentation

Comprehensive medical record documentation is essential when modifiers 25 and 27 are used, especially in combination. Robust documentation serves as the primary defense against claim denials and justifies the medical necessity and distinctness of services rendered. Each service should have separate documentation, detailing the reason for the encounter, the chief complaint, and the medical decision-making process.

The documentation should explicitly demonstrate the E/M service was significant and separately identifiable from any procedure performed, and that multiple facility E/M encounters were distinct. Auditors scrutinize claims with these modifiers, so the medical record must provide sufficient evidence to support each modifier’s use. While not always required, using different diagnosis codes for each service, if clinically supported, can strengthen the claim by showing separate medical necessity.