Gastroenterology Coding Alert

Unsure about your claim? Contact the carrier

There are certain situations in which nearly all insurers will pay for a procedure and a separate E/M service if you use modifier -25 correctly.

In general, most insurance companies (and Medicare) will accept a claim with modifier -25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) when:

1. the gastro treats a patient for two separate co-existing problems (one problem is treated with the procedure, while the other is treated with the E/M service).

2. the physician counsels the patient and coordinates the patient's care for an unrelated condition on the same service date as a procedure performed to evaluate or treat another condition (this can occur after - or in association with - a minor surgical procedure).

3. a single problem prompts an initial E/M service (new patient visit or initial consultation) in which the physician determines that there is a need to perform a minor surgical procedure on the same day as the E/M service.