Coding & Compliance

Billing Modifiers Guide 2026: Modifier 25, 59, GT, 95 & When to Use Each

Modifier misuse is one of the top three reasons for OIG audit referrals in outpatient billing. Modifier 59 alone is listed on the OIG's Work Plan as a high-risk billing pattern — overuse or misuse can trigger post-payment audits and recoupment demands.Source: HHS OIG Work Plan 2025–2026

Billing modifiers are two-character codes appended to CPT codes to tell the payer that a service was performed under circumstances different from what the base code implies. Used correctly, they prevent bundling, clarify distinct services, and protect claims from automatic edits. Used incorrectly, they become a compliance liability. This guide covers the modifiers your billing team will use most frequently — what they mean, when they apply, and where the audit risk lies.

The Quick-Reference Modifier Summary

ModifierNamePrimary Use
25Significant, Separately Identifiable E&MBill E&M same day as procedure
59Distinct Procedural ServiceUnbundle services that are typically bundled
XE / XS / XP / XUSelective Modifiers (X-modifiers)More specific alternatives to Modifier 59
51Multiple ProceduresSecond surgical procedure same day, same provider
GTVia Interactive Audio and VideoTelehealth — commercial payers (pre-2026 legacy)
95Synchronous TelemedicineTelehealth — real-time audio-video visit
93Synchronous Telemedicine — TelephoneAudio-only telehealth visit
26Professional ComponentPhysician interpretation only (no facility fee)
TCTechnical ComponentFacility/equipment cost only (no physician read)
22Increased Procedural ServicesProcedure substantially more complex than usual
50Bilateral ProcedureSame procedure performed on both sides
52Reduced ServicesProcedure not fully completed as described
57Decision for SurgeryE&M on day of or day before surgery, decision made then
24Unrelated E&M During Postoperative PeriodE&M during global period for unrelated condition

Modifier 25 — The Most Commonly Used and Misused Modifier

25
Significant, Separately Identifiable Evaluation & Management Service
Applies to E&M codes only (99202–99215, 99241–99245, preventive codes)

Modifier 25 tells the payer that on the same date a procedure was performed, the physician also provided an E&M service that was significant and separately identifiable — meaning it went beyond the pre-service evaluation that's inherent in any procedure.

USEPatient presents for flu shot and provider also evaluates a new knee complaint, examines the knee, and orders imaging — bill the vaccine + administration code AND an E&M (99213 with Modifier 25)
USEPatient has a laceration repaired and also has a chest complaint evaluated separately — bill the repair code AND E&M with Modifier 25
DON'T USEThe E&M was only to decide to perform the procedure that was already scheduled — that evaluation is bundled into the procedure payment
DON'T USERoutine pre-procedural assessment (e.g., reviewing vitals before an injection) — this is included in the procedure RVU

The documentation test: could the E&M note stand alone as a complete visit, separate from any mention of the procedure? If yes, Modifier 25 likely applies. If the note only discusses the procedure, it doesn't.

Audit risk: OIG and RAC auditors specifically target high-volume Modifier 25 users. If your practice bills Modifier 25 on more than 30–40% of procedure-day encounters, expect scrutiny. Each E&M with Modifier 25 must have distinct documentation to survive a medical record review.

Modifier 59 — The Unbundling Override

59
Distinct Procedural Service
Applies to procedure codes when two services are typically bundled by payer edits

Modifier 59 indicates that a procedure was distinct from another service billed on the same date — different session, different site, separate organ, or a service not typically performed on the same day that was clinically required. It overrides the CCI (Correct Coding Initiative) edit that would otherwise bundle the second code into the first.

USETwo separate lesions removed from different anatomical sites on the same day — each removal is a distinct service
USEAn endoscopy plus a biopsy where the biopsy was taken at a different site than the primary procedure — and the CCI edit lists one as a column 2 code
DON'T USEAs a blanket workaround for any bundled edit — Modifier 59 requires a clinical reason the services were distinct, not just a desire to get both codes paid
DON'T USEWhen a more specific X-modifier (XE, XS, XP, XU) better describes why the service was distinct — CMS prefers X-modifiers over Modifier 59 when they apply

The X-Modifiers: CMS's Preferred Alternative to Modifier 59

In 2015 CMS introduced four sub-set modifiers that are more specific than Modifier 59. CMS instructs MACs to recognize these as equivalent to Modifier 59, but they communicate the reason for distinctness more precisely:

ModifierMeaningWhen to Use
XESeparate EncounterServices were performed during a separate patient encounter on the same date
XSSeparate StructureServices were performed on a separate organ/structure
XPSeparate PractitionerServices were performed by a different practitioner
XUUnusual Non-Overlapping ServiceService is not typically done at the same time as the other billed service

Use XS when two procedures were done on anatomically distinct sites. Use XE when the same provider saw the patient twice in one day for separate visits. Use XP when a different clinician in the group performed the second service.

Telehealth Modifiers: GT, 95, and 93

95
Synchronous Telemedicine Service Rendered via Real-Time Interactive Audio and Video
Medicare and most commercial payers for live video telehealth visits

Modifier 95 is the current standard for live, real-time audio-video telehealth visits under Medicare and the majority of commercial plans. It replaced Modifier GT as the primary telehealth modifier for most payers beginning in 2022 and is now universally preferred.

USESynchronous video visit for any E&M service, behavioral health visit, or other telehealth-eligible service — patient and provider see and hear each other in real time
DON'T USEAudio-only visits (telephone only, no video) — use Modifier 93 instead
DON'T USEAsynchronous services (store-and-forward) — no modifier is used; these have dedicated codes

Modifier 95 must be paired with the correct place of service code: POS 02 (telehealth, not patient home) or POS 10 (telehealth, patient home). The modifier alone is not sufficient — the POS must also match.

GT
Via Interactive Audio and Video Telecommunication Systems
Legacy modifier — still required by some commercial payers

Modifier GT was the standard telehealth modifier before Modifier 95 was adopted broadly. Medicare no longer requires GT — it accepts Modifier 95. However, some commercial payers and Medicaid programs still require GT. Always check the payer's current telehealth billing guidelines before switching.

USECommercial payers that explicitly require GT in their 2026 billing guidelines (verify per payer)
DON'T USEMedicare claims — Medicare doesn't require GT and using it instead of 95 may cause processing issues with some MACs
93
Synchronous Telemedicine Service Rendered via Telephone or Other Real-Time Interactive Audio-Only Telecommunications System
Audio-only telehealth visits

Modifier 93 covers audio-only (telephone) visits where video was not used. Under Medicare, audio-only telehealth is limited to specific circumstances — primarily behavioral health services and situations where the patient is unable to access video technology.

USEBehavioral health E&M visits conducted by telephone only where video was not available or clinically appropriate
DON'T USEVisits where video was available and used — use Modifier 95
DON'T USEBrief telephone check-ins (99441–99443) already describe telephone services — no modifier needed

Modifier 26 and TC — Splitting Global Services

26
Professional Component
Used when a physician reads or interprets a test they did not personally perform

Many diagnostic services (radiology, EKG, EEG, pulmonary function tests) have two components: the technical component (the equipment and technician performing the test) and the professional component (the physician's interpretation and report). When billed without a modifier, the code represents the global service — both components. Modifier 26 isolates just the professional component.

USERadiologist interpreting an X-ray taken at a different facility or hospital — physician bills 71046-26, facility bills 71046-TC
USECardiologist reading an ECG where the EKG machine is owned by the hospital (not the physician practice)
DON'T USEThe physician owns the equipment and performed the test — bill the global code without a modifier

Modifier 51 — Multiple Procedures

51
Multiple Procedures
Second and subsequent surgical procedures performed by the same provider on the same day

When a surgeon performs two or more procedures in the same operative session, the primary (highest-value) procedure is billed without Modifier 51. Each additional procedure is billed with Modifier 51 to indicate it is a secondary procedure. Most payers apply a reduction (typically 50%) to procedures billed with Modifier 51.

USEOrthopedic surgeon performs a rotator cuff repair and a distal clavicle excision in the same session — primary repair billed globally, clavicle excision billed with -51
DON'T USEAdd-on codes (identified in CPT with a + symbol) — add-on codes are exempt from Modifier 51 by definition and should never have it appended
DON'T USEE&M services — Modifier 51 doesn't apply to evaluation and management codes

Modifier 22 — Increased Procedural Complexity

22
Increased Procedural Services
Used when a procedure required substantially greater effort than typically described

Modifier 22 indicates that the work required to perform a procedure was substantially greater than usual — due to unusual patient complexity, anatomical difficulty, complications encountered, or unusual circumstance. Most payers won't automatically increase payment for Modifier 22; it typically requires manual review and a supporting operative note.

USELaparoscopic cholecystectomy converted to open due to extensive adhesions from prior surgery, adding significant operative time and complexity
USEProcedure on a morbidly obese patient where anatomical access required significantly more time and technical effort than the base code assumes
DON'T USEAs a routine add-on to boost reimbursement without documentation of what specifically made the procedure more complex — this is a compliance violation

Always attach an operative note or supporting letter when billing Modifier 22 that explicitly describes what made the procedure more complex and the additional time required. Without this, payers will simply strip the modifier and pay the standard rate.

Modifier 57 vs. Modifier 25 — A Common Confusion

Both Modifier 25 and Modifier 57 apply to E&M services billed on the same day as a procedure — but they're not interchangeable:

Modifier 25Modifier 57
When to useE&M on same day as a minor procedure (global period 0 or 10 days)E&M on the day of or day before a major surgery (global period 90 days), when the E&M was the visit at which the decision for surgery was made
Applied toThe E&M codeThe E&M code
ExampleOffice visit + same-day injectionConsult on Monday, surgery on Tuesday — Monday E&M gets -57
Global period0–10 day global procedures90-day global surgeries
Using Modifier 25 instead of Modifier 57 on a major-surgery same-day E&M — or vice versa — is a billing error that may result in a denial or bundling of the E&M into the surgical global period. The modifier must match the procedure's global period classification.

Modifier 24 — E&M During the Postoperative Period

When a patient comes in during a surgery's global period for a condition completely unrelated to the surgery, the E&M is separately billable with Modifier 24. The documentation must clearly establish that the visit addressed a different diagnosis than the surgical condition. Without Modifier 24, the E&M will be denied as included in the global surgical package.

Modifier Stacking: When Multiple Modifiers Are Needed

CPT allows up to four modifiers per code. When multiple modifiers are used, they must appear in the correct order. The general rule:

  1. Pricing modifier first — modifiers that affect payment (26, TC, 50, 52, 22)
  2. Informational modifier second — modifiers that provide context without changing price (25, 59, 91, 76, 77)

Example: A bilateral procedure with a reduced service: 27310-50-52 (pricing modifiers in front). An E&M with telehealth distinction: 99213-25-95 is acceptable; most payers process the first modifier for payment logic.

Building Modifier Compliance Into Your Workflow

Modifier errors fall into two categories: over-use (appending modifiers to bypass edits without clinical justification) and under-use (missing modifiers that would allow a legitimate service to pay). Both cost money — over-use creates audit exposure, under-use leaves revenue on the table.

At Rcmaxis, we configure payer-specific modifier rules into the claim scrubber before submission — so claims with Modifier 25 trigger a documentation check, claims with Modifier 59 require a CCI edit flag to be present, and telehealth claims automatically verify the POS matches the modifier used.

If your practice is seeing consistent modifier-related denials or you're unsure whether your modifier usage patterns would survive an audit, request a free revenue assessment. We'll review your last 60 days of claims and flag any modifier patterns that carry risk.

References

  1. AMA. (2026). CPT Professional Edition 2026. American Medical Association.
  2. CMS. (2026). National Correct Coding Initiative (NCCI) Policy Manual. Centers for Medicare & Medicaid Services.
  3. HHS OIG. (2025). OIG Work Plan: Modifier 59 Billing Patterns. Office of Inspector General.
  4. CMS. (2022). Modifier 95 and Telehealth Billing Guidelines. MLN Matters MM12427.
  5. CMS. (2026). Claims Processing Manual, Chapter 12 — Physician/Nonphysician Practitioners. CMS Pub. 100-04.
📋

Free Download: The 10-Point RCM Health Check

The billing gaps most practices don't catch until they show up as denials. Get the checklist — free, no spam.

✓ On its way! We'll send the checklist to your inbox within the hour. Or

We don't share your info. Unsubscribe any time.