EM Coding Alert

Question: Should I always append modifier 25 for a minor procedure with an evaluation and management (E/M) service?

Pennsylvania Subscriber

Answer: Modifier 25 (Significant, separately identifiable evaluation and management service by the same physician … on the same day of the procedure or other service) is known for creating confusion in scenarios such as the one you describe. The key to knowing when and how to append this modifier when your provider performs a minor procedure with an E/M is recognizing when the additional work is “significant” and “separately identifiable,” and, therefore, additionally billable.

The first thing to consider is that all billable minor procedures (0-day or 10-day global period) have an E/M component built into the code. This is because it’s common for a physician to do a last-minute check on the patient’s health and answer any additional questions the patient has. 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.

However, when your provider addresses 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. For example, if the patient asked a provider to examine the swelling on a minor sports injury from the day before, but the injury was in no way related to the minor procedure, you could bill for an additional E/M service, with modifier 25, as long as the documentation supported it.

Documentation alert: Documentation in this scenario has to prove evaluation and management. This means there would need to be complete notes outlining the pediatrician’s examination of the injury, any discussion with the patient regarding the injury, the possibility of imaging, pain management, discussion about ways to prevent injury going forward, and any other additional relevant details.