Understanding modifier 25, 59, and other critical modifiers to prevent claim denials

Claim denials frustrate providers and cost private healthcare practices valuable time and revenue. While the reasons vary, some of the most common culprits are CPT code modifiers.

Modifiers clarify the “what” and “why” behind the care you deliver. When you use them correctly, claims process faster, reimbursements arrive sooner, and your revenue cycle stays healthy. When you don’t, you risk delays, rework, and lost revenue.

Let’s break down the modifiers you need to know — starting with 25 and 59 — and how to use them properly to prevent avoidable denials.

CPT modifiers are 2-character codes that add clarity to a service or procedure. They flag when a service differs from the norm — whether due to timing, complexity, or delivery.

For private practices, accurate modifier use is crucial. Small teams don’t always have dedicated billers or coders, and even simple mistakes can trigger denials or payer pushback. Modifiers help you communicate with payers so they understand the full context of care and reimburse you accordingly.

Use modifier 25 when you perform a significant, separately identifiable evaluation and management (E/M) service on the same day as a minor procedure — one with ZZZ, 0, or 10 days post-op in the global surgical package. The visit must be both significant and separately identifiable.

"Significant" means it was above and beyond the minimal E/M included in the procedure payment. "Separately identifiable" means that some portion of the E/M can be easily identified from the bundled E/M. 

Example: A patient comes in for a sore throat. During the visit, you also diagnose and treat an unrelated skin lesion. In this case, modifier 25 tells the payer that the E/M service was above and beyond the typical pre-op evaluation for the lesion procedure.

How to document it:

When you apply modifier 25 correctly and support it with documentation, you avoid denials and demonstrate the value of your time and clinical judgment.

Modifier 59 helps you unbundle services that might otherwise be grouped together. 

Use it when you perform 2 procedures that are truly separate based on:

Example: You excise a benign lesion from a patient’s arm and another from their leg during the same visit. These procedures fall within the same CPT code grouping and would normally be bundled. Modifier 59 indicates that they were performed at separate anatomical sites, which is why separate reimbursement is justified.

Pro tips:

Using modifier 59 the right way keeps your billing clean and reduces the chance of audits or insurance claim rejections.

While modifier 25 and modifier 59 get most of the attention, other CPT modifiers also play a critical role in ensuring clean claims and proper reimbursement.

Here are 4 key modifiers your practice should understand and apply accurately:

Understanding these modifiers helps your team communicate clinical intent clearly to payers — and keeps insurance denials at bay. Train your team to recognize when these modifiers apply, and build reminders into your EHR to reduce manual entry errors.

Avoiding denials starts with solid documentation and consistent billing processes.

Here’s how to stay ahead:

Treat modifiers as tools to tell the full story — not shortcuts or afterthoughts. The clearer your claims, the faster your reimbursements.

Accurate modifier use protects your practice’s revenue and reputation. When you get the details right — like modifier 25 for additional E/M work or modifier 59 for clearly distinct procedures — you avoid friction and speed up payment.

For private practices, every clean claim matters. Build habits now that support documentation, education, and regular billing reviews.

Common CPT modifiers that help prevent claim denials include:​

Using these modifiers appropriately, with proper documentation, can reduce the risk of claim denials. ​

The major global surgical package (90 days postop) has 3 parts: preop, intraop, and postop. The preop portion of the package includes developing the hospital required preop H&P. However, sometimes the surgeon makes the decision to perform surgery on the day before or the day of surgery, often in urgent/emergent situations.

When this occurs, the E/M service may be separately reported from the surgery by adding modifier 57. Modifier 57 can also be added if the patient needs to be recleared for surgery in that preop period because something significant has changed, such as disease progression or a new co-morbidity.

Most coders know that E&M services are included in the post-op period of a procedure, but it is less understood that small procedures performed in clinic, such as minor wound debridement or suture removal, are also included.

f the patient has a complication related to the procedure that requires return to OR or use of a clinic procedure room by the provider who performed the procedure, that work can be separately reported with modifier 78. A benefit of modifier 78 is that it does not restart the global period, which continues to count down from the original procedure.

Incorrect use of modifiers can lead to claim denials, delayed payments, and potential audits. For instance, overuse or misuse of modifier 25 has been associated with increased scrutiny from payers. Ensuring accurate modifier application, supported by thorough documentation, is essential for your clinic to be reimbursed properly. 

Current Procedural Terminology (CPT) modifiers are Healthcare Common Procedure Coding System (HCPCS) Level I modifiers, used with CPT codes to give additional detail about a procedure or service. They are 2 numeric characters.

HCPCS Level II modifiers serve a similar purpose but apply to services and items billed with CPT codes as well as HCPCS Level II codes that describe a wide variety of services — such as ambulance services, durable medical equipment, and Medicare-specific billing scenarios. HCPCS Level II modifiers are 2 characters, but may be letters or numbers. 

Independent practices that bill Medicare or Medicaid may need to use both CPT and HCPCS modifiers, depending on the service.

Start by reviewing denial reason codes from your payers — many specify when a claim is rejected due to modifier issues. Then, audit a small sample of those claims monthly. Look for patterns like overusing modifier 25, incorrect service combinations, or missing documentation.

Practice management and billing platforms can help by flagging high-risk modifier combinations or surfacing trends in denied claims. Ongoing staff education is key to correcting recurring errors.

Yes — in many cases, using a modifier directly influences how a payer reimburses a claim. 

Some modifiers clarify that multiple procedures are unrelated (such as modifier 59), while others signal reduced or professional-only services (modifier 52 or 26). If a modifier is missing or applied incorrectly, the payer may reduce reimbursement, bundle services inappropriately, or deny the claim entirely.

Using modifiers accurately helps ensure fair, timely payment for the work your practice performs.

Want to partner with an EHR+ and billing platform that will help protect your revenue and your time, so you can get back to focusing on patient care? Book a Tebra demo today.