Example A — Separate symptom evaluation + same-day cystoscopy with Botox
Clinical: Patient evaluated for worsening urgency/frequency despite therapy; treatment options reviewed and decision made to proceed with Botox; procedure performed same day.
Code(s): E/M (e.g., 99213) -25 + procedure code (e.g., 52287).
Dx: N32.81 – Overactive bladder; (procedure indication aligns to documentation).

Example B — Hematuria evaluation + diagnostic cystoscopy
Clinical: New gross hematuria evaluated with separate assessment/plan; diagnostic cystoscopy performed same day.
Code(s): E/M (e.g., 99203) -25 + 52000.
Dx: R31.0 – Gross hematuria.

Example C — LHRH injection visit with separate disease-state management
Clinical: Patient presents for scheduled LHRH injection; PSA drawn the same day is rising, and the physician documents a separate assessment and plan (shortened PSA interval, symptom review, discussion of progression risk).
Code(s): E/M (e.g., 99213) -25 + 96402 (+ drug code).
Dx: C61 – Malignant neoplasm of prostate. A same diagnosis is acceptable when the E/M work is documented as significant and separate. If the visit is only “ready for your shot?” plus the injection, do not bill an E/M.

Example D — Hospital consult with same-day stent placement (0-day global)
Clinical: Urologist consulted on the floor for flank pain; reviews history and imaging, makes the diagnosis of an obstructing ureteral stone, and takes the patient for stent placement the same day. The full diagnostic workup — not just surgical prep — is documented.
Code(s): Initial hospital/observation E/M (e.g., 99222) -25 + 52332.
Dx: N20.1 – Calculus of ureter. If the same-day procedure were a 90-day global (e.g., PCNL), use -57 on the E/M instead.

Example E — Routine pre-procedure work only (do not use -25)
Clinical: Visit includes consent and routine prep only for a planned procedure, without separate problem evaluation or management.
Code(s): Procedure code only (no separately reported E/M with -25).
Dx: Align to procedure indication.

• Chief complaint or reason for the visit (problem addressed)
• HPI that describes symptoms/concerns beyond routine procedural prep
• Relevant exam findings
• MDM for the evaluated condition (assessment, risk, options)
• Assessment & plan for the condition being managed — a forward-looking plan (medication started, surgery scheduled, surveillance interval changed), not just the procedure result
• Medical necessity — the reason the extra work was needed that day
• Clear separation between E/M documentation and the procedure note
• Separate diagnoses or additional problems addressed (when applicable)

• Use headings such as “Evaluation and Management” and “Procedure Note” to show separation in the record. Payers’ first-pass reviews are increasingly automated — make the separation impossible to miss.
• Consider a lead-in statement in the note: “A significant and separately identifiable E/M service was provided as follows: …” followed by the separate work performed. Automated and human reviewers both respond to explicit language.
• Avoid EHR templates that auto-append -25; the note, not the template, must support the modifier for that patient on that day.

• Denial: “E/M is bundled into the procedure.”
  Fix: Document the separate complaint, MDM, and plan that go beyond routine procedure work; keep notes clearly separated.
• Denial: “Insufficient documentation for -25” after a records request.
  Fix: Ensure the E/M includes HPI, exam, and MDM tied to a problem evaluated that day (not just consent/prep). Several payers now run prepayment review programs that pull records on every -25 claim.
• Denial: Auto-added -25 patterns flagged for audit.
  Fix: Avoid “always add -25” templates; use -25 only when the note supports significant, separately identifiable work. Improper -25 use has driven False Claims Act settlements and OIG work-plan scrutiny for two decades.
• Denial: Same diagnosis for E/M and procedure triggers review.
  Fix: A separate diagnosis is not required, but the note must clearly show additional evaluation and management work.
• Appeal tactic: Denial upheld after quoting NCCI rules in the appeal.
  Fix: The payer already knows the rules — that is why it denied. Build the appeal around the documentation: walk the reviewer through exactly where the note shows significant, separately identifiable work and why it was medically necessary that day. Escalate to independent review when warranted; treat appeals as a long game measured in the aggregate, not claim by claim.

Key rule: Modifier -25 is appended to the E/M code, never the procedure code.

• 99202–99205 – Office or other outpatient visit, new patient
• 99211–99215 – Office or other outpatient visit, established patient
• 99221–99223 – Initial hospital inpatient or observation care
• 99231–99233 – Subsequent hospital inpatient or observation care
• 99238–99239 – Hospital discharge day management
• 99281–99285 – Emergency department visits

• 52000 – Cystourethroscopy (0-day global)
• 52287 – Cystourethroscopy with injection(s) for chemodenervation of the bladder (0-day global)
• 52332 – Cystourethroscopy with insertion of indwelling ureteral stent (0-day global)
• 55707 – Biopsy, prostate, transrectal, ultrasound guided (0-day global)
• 96402 – Chemotherapy administration, subcutaneous or intramuscular; hormonal anti-neoplastic (LHRH agonist injections)
• 96372 – Therapeutic, prophylactic, or diagnostic injection; subcutaneous or intramuscular
• 51728 / 51729 – Complex cystometrogram with voiding pressure studies (± urethral pressure profile) (0-day global)

Reminder: Codes with an XXX global (like 96402 and 96372) have no global package, but NCCI bundles E/M into them anyway — a same-day E/M still needs -25 to be paid.

Do not use -25 when the E/M represents routine pre-procedure work (consent, preparation, routine H&P tied only to the procedure), and do not use -25 for the decision for major surgery — that is modifier -57 (e.g., decision for PCNL or vasectomy, both 90-day globals).

Modifier -25 does not correspond to a specific diagnosis code. However, documenting the condition evaluated during the E/M supports medical necessity.

• R31.0 – Gross hematuria
• N32.81 – Overactive bladder
• R35.0 – Frequency of micturition
• R39.15 – Urgency of urination
• N40.1 – Benign prostatic hyperplasia with lower urinary tract symptoms
• C61 – Malignant neoplasm of prostate

Tip: A separate diagnosis is not required, but it can strengthen documentation when the E/M addresses a distinct problem. When the diagnosis is the same for both services, the note itself must carry the argument — and avoid unspecified codes where a specific one exists; payers penalize “unspecified.”

The medical record must clearly demonstrate that the E/M service was separate and significant relative to the procedure performed.

• Chief complaint – Reason for the visit
• HPI – Symptoms or concerns addressed
• Exam – Relevant findings
• MDM – Decision making related to the evaluated condition
• Assessment & plan – Treatment plan for the condition being managed
• Medical necessity – Why the evaluation was needed
• Clear separation – E/M documentation distinct from the procedure note
• Separate diagnoses or clinical problems addressed – When applicable

Evaluation and Management
Chief Complaint: Patient presents with worsening urinary urgency and frequency despite current therapy.
HPI: Progressive urgency and urge incontinence over three months despite anticholinergic therapy. Symptoms every 1–2 hours with nocturia three times nightly.
Assessment: Refractory overactive bladder; urgency urinary incontinence.
Plan: Discussed options including intravesical Botox therapy; risks/benefits reviewed; patient elected to proceed today.

Procedure Note
Procedure: Cystoscopy with bladder Botox injection.
Indication: Refractory overactive bladder.
Details: Flexible cystoscope inserted; bladder inspected; 100 units injected across 20 detrusor sites sparing trigone; tolerated well.

• Document the procedure in the EHR’s procedure section (or a clearly set-off block) and the E/M assessment/plan in its own section.
• Consider the explicit lead-in: “A significant and separately identifiable E/M service was provided as follows: …” — helpful with both automated first-pass review and human auditors.
• On appeal, argue from the note — not from the rulebook. Show the reviewer where the separate work lives in the documentation.

• -25: Significant, separately identifiable E/M, same day as a 0/10-day-global or NCCI-bundled service
• -57: Decision for surgery — E/M resulting in the decision to perform a 90-day-global procedure
• -24: Unrelated E/M during a post-op global period — can combine with -25 when an unrelated E/M and a new same-day procedure occur inside another procedure’s global
• Sequencing: When both apply to one E/M line, list the same-day payment modifier first (-25), then the global-period modifier (-24). Informational modifiers go last.

• The visit-complexity add-on G2211 cannot be reported when the E/M requires modifier -25.

• Cystoscopy (52000) – 0-day global
• Bladder Botox injection (52287) – 0-day global
• Stent placement (52332) – 0-day global
• Prostate biopsy (55707) – 0-day global
• Urodynamics (51728/51729) – 0-day global
• Vasectomy (55250) – 90-day global → use -57 for the same-day decision, not -25
• Confirm using your MAC/payer fee schedule.

• Several commercial payers run prepayment documentation review on -25 claims or pay -25 E/M at reduced rates; rules vary by plan, not just by payer.
• Modifier -25 has been on the OIG work plan for two decades, and improper use has produced False Claims Act settlements in urology.
• One denial-avoidance option when a same-day E/M is repeatedly denied with a diagnostic study interpretation: bill the study global on the test date and schedule the E/M discussion (e.g., telehealth) on a separate date when clinically appropriate.

Reminder: Improper modifier -25 usage is a common cause of payer denials and compliance audits — and proper usage is worth defending. E/M represents over half of the average physician’s work RVUs, and a large share of those visits require -25.

Facility focus: Facilities typically report the procedure performed, supplies, and drugs administered (when applicable). Modifier -25 generally does not apply to facility billing of these procedures.

• 52000 – Cystourethroscopy (separate procedure)
• 52287 – Cystourethroscopy with injection(s) for chemodenervation of the bladder
• 52332 – Cystourethroscopy with insertion of indwelling ureteral stent
• 55707 – Biopsy, prostate, transrectal, ultrasound guided
• 96402 – Chemotherapy administration, subcutaneous or intramuscular; hormonal anti-neoplastic

• Modifier -25 generally does not change facility reporting methodology. (Hospital outpatient clinic E/M reporting uses G0463 under OPPS with its own edit rules — follow facility policy.)
• Ensure the physician operative report aligns with facility charge capture and nursing documentation
• Confirm payer/MAC guidance and facility compliance policy

Facilities typically report diagnosis codes that match the physician’s documented indication for the procedure to support medical necessity.

• R31.0 – Gross hematuria
• N32.81 – Overactive bladder
• N40.1 – Benign prostatic hyperplasia with lower urinary tract symptoms
• R39.15 – Urgency of urination

Facility tip: Diagnosis mismatches between physician and facility claims may trigger payer review.

• Procedure performed – What was done and the clinical indication
• Physician operative report – Present and consistent with the facility record
• Medication administration documentation – When applicable
• Drug units administered and wastage – When required by payer/facility workflow
• Setting verification – Outpatient/ASC/HOPD as applicable
• Record alignment – Op note, nursing record, supply log, and charge capture tell the same story

Clarify impact: Modifier -25 generally does not change facility reimbursement methodology because it applies to physician E/M reporting.

• Modifier -25 audits may request both physician and facility documentation
• Documentation mismatch between surgeon notes and facility records creates audit risk
• Payers frequently analyze modifier -25 billing patterns — several run prepayment documentation review on -25 claims
• Automated payer systems may deny E/M services billed with procedures pending documentation review

Operational tip: When a same-day E/M is billed by the physician, ensure the facility record supports the same clinical story and timing of services.