Gastroenterology Coding Alert

Question: A physician in our clinic said you do not need different diagnosis codes to use modifier 25 for reporting an E/M service on the same date as a procedure. However, I've always added modifier 25 to the E/M when I bill more than one procedure, pointing the primary diagnosis to the E/M and a secondary diagnosis to the other procedure. Which way should I go?Indiana SubscriberAnswer: You don't need to use a different diagnosis code in order to use modifier 25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service). Attaching different diagnosis codes to the E/M and the procedure doesn't necessarily support a separately reportable E/M service. Your key to separately reporting the E/M service lies in whether your doctor performed and documented work beyond what is considered to be part of the procedure.In short, when [...]