Internal Medicine Coding Alert

Question: Can we report both a urinalysis and an E/M code? Is a modifier required?


Alabama Subscriber

Answer: When the internist performs an office visit and then also provides an ancillary service (such as a lab test) to determine a diagnosis or the treatment plan, you can typically report both services without appending modifier 25. Keep in mind that CMS does not require you to append modifier 25 to E/M codes when you perform the E/M along with a procedure that does not have a global period.

For example, along with an exam, the internist or nurse performs a urinalysis, which is an ancillary service, for a patient with suspected diabetes.

In this case, you could report the appropriate E/M code (such as 99212, Office or other outpatient visit for the E/M of an established patient ...) along with 81002 (Urinalysis, by dip stick or tablet reagent for bilirubin, glucose, hemoglobin, ketones, leukocytes, nitrite, pH, protein, specific gravity, urobilinogen, any number of these constituents; non-automated, without microscopy) without using modifier 25 (Significant, separately identifiable E/M service by the same physician on the same day of the procedure or other service).