General Surgery Coding Alert

Question: I am having trouble with my modifier 25 coding, specifically with my documentation to prove a separate E/M service. What documentation should I look for to report modifier 25?

Montana Subscriber

Answer: When you are coding an encounter during which the physician provides an E/M service and performs another procedure, you should separate the documentation  and make sure there are two distinct processes. If you follow this documentation advice, your accuracy should improve on claims containing modifier 25 (Significant, separately identifiable E/M service by the same physician on the same day of the procedure or other service).

When examining the E/M documentation, make sure you have the history, exam and medical decision-making in the patient's chart. Also, be sure you have documentation to show the E/M service's distinct nature. For the procedure note, make sure it includes notes and diagnosis codes that explain the reason for the procedure.

Diagnosis coding: For modifier 25 claims, you should include a diagnosis code (or codes) to represent accurately the reason for the E/M service and the procedure. Remember, the E/M and the procedure could end up with the same diagnosis code, but this is acceptable.

-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,- according to CPT. However, many payers have edits in place that will not allow payment for both services when you cite a single diagnosis, so be sure to report multiple diagnoses when appropriate.