Orthopedic Coding Alert

To ease payment for your modifier 25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) claims, check your claim against the following:

1. Append modifier 25 to the E/M service only when the same-day procedure is a minor procedure (that is, the procedure does not have a 90-day global period). For E/M services on the same day as a major procedure (a procedure with a 90-day global period), modifier 57 (Decision for surgery) is appropriate.

2. Have complete and separate documentation for the E/M service, apart from documentation for any other services/procedures the physician provides that day. Treat E/M codes as part of a different encounter. Documentation should independently support every code you claim.

3. Be sure that the E/M service you report is significant (in a best-case scenario, documentation should support at least a level-three patient encounter, 99203 or 99213).

4. Whenever possible, attach a different diagnosis to the E/M service. Although not required, a unique diagnosis helps establish the separately identifiable nature of the E/M service.

5. Use the appropriate narrative boxes on the CMS-1500/electronic form to explain the significant, separately identifiable nature of the E/M service.

6. Be certain that you are not billing for care included in a previous surgery's global period. You may not separately report E/M services the surgeon provides during the global period of a related procedure.

Note: If the physician provides an E/M service during the global period of an unrelated procedure, however, you may report the appropriate E/M service code with modifier 24 (Unrelated evaluation and management service by the same physician during a postoperative period) attached.