Modifier-25

Modifier 25 Update: Policy Postponed & Revised

We are pleased to share that Blue Cross Blue Shield of Michigan (BCBSM) and Blue Care Network have postponed implementation of their proposed modifier 25 reimbursement policy, following strong advocacy from osteopathic physicians and the AOA.

In response to provider concerns, BCBSM has announced revisions and clarifications to the policy. Key updates include:

  • Clearer definition of a “minor procedure” (0- or 10-day global period, office/outpatient, low risk, minimally invasive)
  • Specific criteria for modifier 25 use, including that the E/M service must be significant, separately identifiable, and above and beyond usual pre-/post-operative care
  • No change to the list of applicable E/M codes (99202–99205, 99212–99215)
  • Important exclusion: Emergency room visit proximity – a same-day E/M with modifier 25 following an ER visit (within one calendar day) will not be subject to the 50% reduction (provided the ER claim is processed first)

The postponement means the policy is not yet in effect, giving us time to continue advocating for fair payment that recognizes distinct physician work and protects patient access to care. April 2026 Provider update.

Thank you to everyone who raised concerns – your voice made a difference. We will keep pushing for a final resolution that is fair, transparent, and clinically sound.

The AAO is grateful to the American Osteopathic Association (AOA) for their leadership in securing this postponement. The AAO remains committed to advocating for our members every step of the way. If you have concerns, email [email protected].

Modifier-25: Significant, Separately Identifiable E/M Service

Modifier-25 can be used to report accurately when a significant, separately identifiable E/M service is performed on the same day of service as a procedure (OMT).

The take-away: It’s important to understand what Modifier-25 means to ensure your claims aren’t denied.

OMT was assigned a 000-day global designation by CMS and, therefore, falls into the category of an endoscopic or minor surgical procedure. As a result of this global period, if a practitioner reports Evaluation and Management (E/M) services and OMT services on the same date of service, then the E/M services will be denied or paid with the payment for OMT. However, both CMS and the AMA CPT provide guidance when exceptions to the global period rules apply.

CMS NCCI edits and the CPT guidelines for Osteopathic Manipulative Treatment (OMT) have stipulated that E/M services and OMT can be reported on the same date of service with the use of Modifier-25.

There are two key definitions for Modifier-25:

Modifier-25 is appropriate to use when the patient’s condition requires a significant, separately identifiable E/M service above and beyond the usual pre-service and post-service work associated with the procedure. The E/M service may be for the same symptoms or condition that warranted the OMT. Therefore, different diagnoses do not need to be reported when an OMT and an E/M service are reported on the same date of service.

CPT OMT Modifier-25 Guidelines:

Modifier-25 is used when the patient’s condition requires a significant, separately identifiable E/M service above and beyond the usual pre-service and post-service work associated with the procedure. The E/M service may be related to the same symptoms or condition for which the OMT was provided. Therefore, different diagnoses are not required when reporting both the OMT and E/M service on the same date.

CPT Appendix A Modifier-25 Guidelines:

Modifier-25 is used when the patient’s condition requires a significant, separately identifiable E/M service, above and beyond the other service provided or beyond the usual preoperative and postoperative care associated with the procedure performed.