Gastroenterology Coding Alert

Question: We know that most insurers say separate diagnoses are not required to use modifier 25, but it seems like we never get paid unless we use separate diagnoses for the procedure and the E/M code. Why is that?

Minnesota Subscriber

Answer: You are correct in noting that insurers don’t typically require separate diagnoses, but there’s a chance that you aren’t using diagnoses that support the medical necessity for both separate services.

When reporting any E/M service, you must link it to a diagnosis that explains the reason the physician performed it, and it’s possible that your payer may not find that medical necessity in your notes to support the use of modifier 25 (Significant, separately identifiable evaluation and management service by the same physician or other qualified health care professional on the same day of the procedure or other service) on your claim.

Important: The E/M service needn’t be unrelated to the other service(s) or procedure(s) the physician provides on the same day. CPT^® specifically states, “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.”

But separate diagnoses, when available, can further help to demonstrate the distinct nature of the E/M service — especially when dealing with payers other than Medicare. So, if you do happen to have separate diagnosis codes for the procedure and the E/M, you should use them, but if you don’t have different ones, don’t go looking for separate diagnoses to bill.

A simple example is a patient seen for rectal bleeding, and the decision is made to perform a same-day anoscopy exam, which finds internal hemorrhoids. The symptoms would be the diagnosis for the visit, and K64.8 (Other hemorrhoids) for bleeding internal hemorrhoids would justify the anoscopy.