Inpatient Facility Coding & Compliance Alert

Question: I need guidance on exactly how and when to separately report an E/M service along with a procedure using modifier 25. I have heard that indiscriminate use of this modifier may invite payer scrutiny. Please help.

Florida Subscriber

Answer: Yes, that is very true. Some coders view 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) as a “magic bullet” and they always add a 25 modifier to E/Ms done on the same day as a procedure because they feel that is the only way they can get paid for both services. Don’t fall into that trap. You will set your facility up for denials, and worse, payer audits. 

Report this modifier only with the E/M service when the provider also completes a separate service or procedure on the same date of the E/M care. The provider’s documentation should support that he performed an E/M service that was significant and separately identifiable from the work included in another service or procedure.

Identify E/M HEM before adding 25: If a patient comes to see the physician because of several medical problems, and the physician orders a cystoscopic examination to further evaluate one of these problems, the E/M services should be separately identifiable from the cystoscopy and reported with modifier 25. In this particular case the physician addressed more than one problem, each requiring a separate history, examination and medical decision-making (HEM).

You should use modifier 25 only with services that are “significant, separately identifiable” and “above and beyond the usual preoperative and postoperative care associated with the procedure.”

All procedures include some services related to preoperative patient evaluation and management, but a completely separate E/M should include its own HEM. In other words, the physician needs to determine whether the problem is significant enough to require additional work to perform the key components of the problem-oriented E/M service.

A complicating factor is that the CPT® description of the 25 modifier indicates that different diagnoses are not required to use the modifier.  Even if there are not differentiating diagnoses, the burden of proof is with the provider to justify E/M services that are distinct and separate from the procedure.

Best bet: You may scan through the documentation and cross out anything that is directly related to the procedure performed. Then, review the remaining documentation to determine if it is indeed significant, separately identifiable and medically necessary.