Gastroenterology Coding Alert

Question: Our claim for an E/M and a procedure was audited and then the payer wanted money back, saying we didn't demonstrate medical necessity for the separate E/M service. What are we missing?

Codify Subscriber

Answer: There is only one way to prove medical necessity for the separate E/M and procedure, and that is to have clear documentation. Typically, you won't submit documen­tation on your modifier 25 claims, but if the payer denies the claim you'll have to provide documentation on appeal, Witt explains.

A separate diagnosis is always a good method to prove significantly separate services, but you won't always have different ICD-10 codes for the procedure and the E/M-25. Proper documentation for some E/M-25 encounters might include a separate plan of care for theproblem - for example, prescription drug management or ordering studies. Also, if you make it clear in the documentation that the provider reached thedecision to perform the procedure after performing the history and exam, and the physician notes it in his plan of care, it could go a long way toward solidifying your E/M-25 claims.

Bottom line:  No matter how you do it, medical record documentation is key to substantiating that an E/M was medically necessary in addition to the work involved in a procedure for the same patient during the same visit. Make sure to get your notes right before submitting an E/M-25, so you'll be ready if the payer requires you to appeal the claim. Different diagnoses for the two services are not necessary.