ED Coding and Reimbursement Alert

Question:  I am having trouble with my modifier 25 coding, specifically with my documentation to prove a separate evaluation and management (E/M) service. Can you offer any advice on how to document my modifier 25 claims?

Montana Subscriber

Answer:  When you are coding an encounter in which the physician provides an E/M service and performs another procedure, you should separate the documentation for both services and make sure there are 2 distinct processes. If you follow this documentation advice, it should improve your accuracy on claims containing modifier 25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service).

When documenting the E/M, make sure you have the history, exam, and medical decision-making in the patient’s chart. Also, be sure to include documentation to show the distinct nature of the E/M. For the procedure note, make sure to include notes and diagnosis codes that explain the reason for the procedure.

Diagnosis coding: For modifier 25 claims, you should include a diagnosis code (or codes) to accurately represent the reason for the E/M service and the procedure. Remember, the E/M and the procedure could end up with the same diagnosis code, but this is acceptable. According to CPT®, “The E/M service may be prompted by the symptom or condition for which the procedure and/or service was provided. As such, different diagnoses are not required for reporting of the E/M services on the same date.” However, many payers have edits that will not allow payment for both services when a single diagnosis is employed so be sure to report multiple diagnoses when appropriate.