General Surgery Coding Alert

Question: Do the recent changes to E/M codes alter the way we use modifier 25?

California Subscriber

Answer: The rules for using 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) haven’t changed, but in some ways, the changes in E/M coding rules may alter how you apply the modifier.

Flashback: It used to be that you had to check whether the provider documented enough data in the history and physical exam (H&P) sections of their progress notes so that anyone reviewing them would be able to easily see the separate E/M service they performed in addition to the procedure.

Now that you select the E/M codes solely based on time spent or the medical decision making (MDM) component, the lines of where an E/M service ends and a procedure begins have become more blurred.

With the present CPT^® guidelines, “the extent of [H&P] is not an element in selection of the level of office or other outpatient codes.” But you still must document that the physician performed H&P, which is part of the E/M service.

Do this: To use modifier 25, the documentation must show an H&P that is separate from the H&P included in the E/M service. For that reason, you need to encourage your physicians to keep up good H&P documentation habits, even though H&P levels are no longer needed for the E/M service level.