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 Subscriber

Answer: 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 using modifier 25, the diagnosis associated with the E/M service can be the same as or different from the diagnosis associated with the same-day procedure. The CPT manual description of modifier 25 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."

Key: Your gastroenterologist's documentation should clearly establish that the E/M involved work over and above that typically associated with the procedure, and that the encounter's sole purpose was not to perform the procedure.