Why it matters in orthopedics

Orthopedic clinic days mix visits with minor procedures: joint injections and aspirations (CPT 20600–20611), splinting and casting. Medicare treats procedures with 0- or 10-day global periods as minor procedures and includes same-day visits in their payment, so the E/M is paid only when it is separately identifiable and carries modifier 25.

Modifier 25 is also a long-running compliance focus. OIG’s 2005 report found that 35% of modifier 25 claims Medicare allowed in 2002 did not meet program requirements, and a 2026 OIG Work Plan project is reviewing E/M services paid on the same day as minor surgery without modifier 25. In July 2026, CMS proposed paying the lower-valued service at 50% when an office or outpatient E/M and a global procedure share a day; as of October 2026, that proposal is not final.

How it works

• Use 25 only on E/M codes, and only when the same physician or qualified practitioner provides the E/M on the same day as a procedure (Medicare Claims Processing Manual, Chapter 12, §30.6.6.B).

• The E/M must be significant, separately identifiable and above and beyond the usual pre- and post-procedure work.

• The decision to perform a minor procedure is part of the procedure’s payment, for new and established patients alike. Being a new patient is not enough by itself (NCCI Policy Manual, Chapter I, Sections D and E, revised January 1, 2026).

• Different diagnoses are not required.

• Medicare does not require records with the claim, but both services must be documented. Contractors that find high, unsupported modifier 25 use can review records, educate the practice and add prepayment screens.

• When an E/M on the day of or the day before a 90-day global surgery results in the decision to operate, use modifier 57, not 25.

• Modifier 59 is not appended to an E/M; 25 is the E/M modifier.

All of these rules sit inside the global surgical package.

Orthopedic example

A 58-year-old established patient with right knee osteoarthritis arrives for a scheduled corticosteroid injection and mentions new, worsening left hip pain. The physician examines the hip, orders imaging and starts a treatment plan, then injects the knee. The practice bills 20610 with RT for the knee and an E/M with modifier 25 for the hip evaluation, with the level based on the hip work only.

If the visit had covered only the knee check before the injection, 20610 alone would be correct. Our injection-day guide walks through more knee, shoulder and hip scenarios.

Common denial triggers

• The E/M note documents only the pre-injection assessment and consent.

• Modifier 25 is appended to the procedure code. UnitedHealthcare’s Procedure to Modifier Policy (2026R0119A) does not pay a surgical code billed with 25.

• 25 is used instead of 57 for a decision for major surgery.

• The E/M level counts work that belongs to the procedure.

• Payer-specific rules are missed. Cigna’s Reimbursement Policy M25 (last updated February 20, 2026), for example, requires records with the initial claim for certain NCCI edits.

When the E/M is bundled into the procedure, remittances commonly show CARC CO-97.

How to prevent or fix

• Write the E/M and the procedure note separately, and report the E/M only when it stands on its own.

• Level the E/M on the separate work alone, and leave procedure time out of time-based leveling.

• Review E/M-plus-procedure claims before submission, and track modifier 25 rates by provider.

• Appeal denials with records when separate work is documented; otherwise accept the denial and educate.

• Watch the CY2027 final rule; our CY2027 fee schedule overview covers the proposal.