Gastroenterologists frequently evaluate patients whose condition ultimately requires an endoscopic procedure on the same day. In these situations, an important coding question arises: When may the physician separately report the evaluation and management (E/M) service with modifier 25?
The answer depends on whether the E/M service is significant and separately identifiable from the work normally associated with the procedure.
A GI Emergency: E/M or Just Pre-Procedure Work?
Consider the following scenario:
A 56-year-old woman with alcohol-associated cirrhosis presents to the emergency department after five episodes of large-volume hematemesis. She is hypotensive at 82/50 mmHg, tachycardic at 116 beats per minute, and has a hemoglobin of 7.2 g/dL. She also takes rivaroxaban for paroxysmal atrial fibrillation. CT imaging demonstrates large esophageal varices.
The patient is admitted to Medicine, and Gastroenterology is urgently consulted.
The gastroenterologist performs a bedside evaluation, reviews the patient's history, laboratory results, imaging, anticoagulation, and hemodynamic status, and develops an immediate treatment plan. The physician recommends transfusion, intravenous PPI and octreotide, ceftriaxone, reversal of anticoagulation with four-factor prothrombin complex concentrate, continued resuscitation, and urgent endoscopy.
Following initial stabilization, an EGD is performed later that same day. A large distal esophageal varix with active spurting hemorrhage is identified and successfully treated with endoscopic variceal ligation.
Can the gastroenterologist report both the E/M service and the therapeutic endoscopy?
In this scenario, yes, assuming the documentation and other requirements of the selected E/M code are met.
Why Modifier 25 Is Appropriate
Modifier 25 is appended to an E/M code when a physician provides a significant, separately identifiable E/M service on the same day as another procedure or service.
The key is determining whether the E/M work goes beyond the usual pre- and postoperative work associated with the procedure.
In the example above, the gastroenterologist did much more than confirm the indication for EGD or assess whether the patient could safely undergo the procedure. The physician evaluated and actively managed a critically ill patient with acute GI hemorrhage, hemodynamic instability, cirrhosis, severe anemia, and concurrent anticoagulant therapy.
That work included significant medical decision-making related to resuscitation, transfusion, pharmacologic therapy, anticoagulation reversal, and the urgency and timing of therapeutic intervention. The subsequent endoscopy addressed the bleeding source through a distinct procedural service.
The E/M service may therefore be separately reportable with modifier 25 appended to the E/M code.
A different diagnosis is not required. The same acute GI hemorrhage can appropriately support both the E/M service and therapeutic endoscopy when the documentation demonstrates distinct physician work.
Correct Coding / Incorrect Coding
✓ Correct Coding
Because the gastroenterologist performs and documents a medically necessary E/M service that is significant and separately identifiable from the usual work of the procedure, the E/M service may be reported with modifier 25 in addition to the applicable endoscopic procedure code.
In this example, the gastroenterologist may report:
- 99223-25 for the initial hospital inpatient or observation E/M service; and
- 43255 for the EGD with control of bleeding.
✗ Incorrect Coding
Modifier 25 is reported simply because the physician evaluated the patient before performing an endoscopy. Routine pre-procedure activities—such as confirming the indication, reviewing interval history, obtaining consent, or determining that the patient remains appropriate for the planned procedure—do not, by themselves, support a separately reportable E/M service.
Remember: Modifier 25 is appended to the E/M code, not the procedure code.
Documentation Is Critical
The medical record should make the distinction between the E/M and procedural work clear to a reviewer. For an acute GI bleed, documentation may include the severity of the patient's presentation and hemodynamic instability; relevant laboratory and imaging findings; assessment of anticoagulant therapy; transfusion and resuscitation recommendations; pharmacologic management; communication with other treating clinicians; and the physician's medical decision-making regarding urgent intervention. Simply documenting “separate E/M performed” is not sufficient. The record itself should demonstrate the work.
CY 2027 MPFS: A New Payment Proposal for Modifier 25 Services
The CY 2027 Medicare Physician Fee Schedule (MPFS) proposed rule, released in July 14, 2026, introduces an additional consideration for certain E/M services furnished on the same day as a procedure.
CMS proposes a payment reduction when a separately identifiable office/outpatient E/M visit is furnished by the same physician—or a physician in the same practice—on the same day as a procedure with a 0-, 10-, or 90-day global period.
Under the proposal, the highest-priced applicable service would generally be paid at 100% of the MPFS amount, while the other applicable service or services would be paid at 50%.
CMS maintains that efficiencies may occur when an E/M visit and procedure are furnished together and that the current payment methodology may therefore result in duplicative payment for certain resources.
Importantly, CMS is not proposing to eliminate modifier 25 or change the fundamental standard for determining whether an E/M service is separately reportable. Instead, the proposal would change how Medicare pays for certain appropriately reported same-day services.
For gastroenterologists, that distinction matters. A service may be correctly coded and fully supported by the medical record yet, if the proposal is finalized, still be subject to a Medicare payment reduction.
The policy is currently proposed for CY 2027 and is not yet in effect.
Bottom Line
When a patient's condition requires meaningful evaluation and management beyond the routine work associated with an endoscopic procedure, modifier 25 remains an important mechanism for accurately reporting the physician's work.
As CMS considers changes to payment for same-day E/M and procedural services for CY 2027, accurate coding and clear documentation demonstrating that the E/M service is separately identifiable from the procedural work remain essential. Look for an update in the GI Billing Playbook following publication of the final CY 2027 Medicare Physician Fee Schedule rule in November 2026!
Author
Edward Sun, MD, MBA, FASGE, is Associate Medical Director at Peconic Bay Medical Center. Dr. Sun serves as Chair of the ASGE Reimbursement Committee.