Ob-Gyn Coding Alert

To ensure additional reimbursement and fewer denials when using modifier -25, make sure you can demonstrate that your E/M encounter and your other procedures are separately identifiable.
 

By using modifier -25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service), you're asking for separate payment for an E/M service that the ob-gyn performed on the same day as a procedure or other service. Just make sure you have the documentation to prove it.
 
Follow these three simple steps to determine whether you've made your case for using modifier -25: 1. Prove You Can Separately Identify the Service
CMS dictates that all procedures that include a global package (0, 10 or 90 days), from simple laceration repairs to common diagnostic tests, have an inherent E/M component. Consequently, Medicare will not pay you for an additional E/M service unless it is significant and separately identifiable and goes beyond the E/M service you would normally provide as a part of the procedure.
 
Some practices wrongly define "significant" to mean the E/M visit must be at least a level-four or level-five code (for example, 99204 or 99215, Office or other outpatient visit for the evaluation and management ...). But the September 1998 CPT Assistant states, "To use modifier -25 correctly, the chosen level of E/M service needs to be supported by adequate documentation for the appropriate level of service ... modifier -25 is not restricted to any particular level of E/M service."
 
"The 'significance' is that the problem warrants further workup or treatment, regardless of the complexity of the problem," says Carol Pohlig, BSN, CPC, RN, senior coding and education specialist at the University of Pennsylvania department of medicine in Philadelphia. "You should not report an E/M in addition to the procedure if the physician is commenting on self-limiting or minor problems that did not require a plan of care."
 
So you should append modifier -25 to your E/M code if the ob-gyn believes that he or she performed an E/M service that was completely independent of the procedure. But you don't have an E/M visit if the physician hasn't documented history, exam and medical decision-making. The doctor should clearly delineate these in addition to any notes about procedures performed.
 
To demonstrate that the E/M service qualifies as an independent evaluation, you should physically separate the E/M notes from the procedure documentation in the medical record. The ob-gyn should document the history, exam and medical decision-making in the patient's chart and record the procedure notes on a different sheet attached to the chart. Using this documentation method, a reviewer can clearly identify the two services, each of which is individually supported by documentation.
 
"Far too often, the ob-gyn will [...]