EM Coding Alert

Getting paid for modifier 25 claims has often been tricky.

Check out these pointers on earning the payment your providers deserve.

Myth 1: Modifier 25 Is Always Appropriate for Minor Procedure + E/M

All billable minor procedures (0-day or 10-day global period) already include an inherent small evaluation and management (E/M) component to gauge the patient’s overall health and the medical appropriateness of the service. Since the decision to perform a minor procedure is included in the payment — the relative value units (RVUs) include pre-service work, intra-service time, and post-procedure time — an E/M service should not be reported separately.

When your providers address an additional problem at the time of another service/procedure and the patient’s condition requires work above and beyond the other service provided or the usual care associated with the procedure performed, you should report the separate E/M with modifier 25 appended to get paid for both services.

Before you go reaching for modifier 25 (Significant, separately identifiable evaluation and management service by the same physician … on the same day of the procedure or other service) make sure you’re using it because a minor procedure or other service and a separate and significant E/M service were performed:

• On the same patient;
• By the same physician; and
• On the same date.

The key is recognizing when the additional work is “significant” and, therefore, additionally billable.

Myth 2: Aim for Different Diagnosis Codes

Different diagnosis codes are unnecessary; in some cases, the diagnosis code for the E/M and procedure codes will be the same. Claim success hinges on the E/M service being separate and significant; the documentation must substantiate this, and the physician’s work must be medically necessary.

Typically, if the E/M service is unrelated to the minor procedure (i.e., for a different concern/complaint) or occurs due to exacerbation of an existing condition or other change in the patient’s status, the E/M service may be reported separately if it is independently supported by documentation.

Myth 3: Utilize Physically Separate Documentation

While you don’t need separate notes, physically separating the documentation for the E/M service from documentation for the other same-day procedure or service may help. What is necessary is having a medical record that demonstrates the necessity of and justification for the services performed. Payment hinges on the provider appropriately and sufficiently documenting both the medically necessary E/M service and the minor procedure/other service in the patient’s office note to support the claim for these services.

Tip: Make sure your providers show their extra cognitive work, as it will serve a critical role when the payer reviews the claim.