Pediatric Coding Alert

Easily distinguish a significantly separate E/M service from a minor related E/M that's included in a procedure with this handy tool.

You don't have to sacrifice E/M service pay just to keep your practice in the clear from payers that are scrutinizing claims containing modifier 25. Instead, confidently label a service as separate and significant using this checklist provided by Denae M. Merrill, CPC-E/M, owner of Merrill Medical Management in Saginaw Mich.

Before using modifier 25, ask four questions:

1. Why is the patient being seen? Are there signs, symptoms and/or conditions the provider must address before deciding to perform a procedure or service?

Yes, an E/M service might be medically necessary with modifier 25

No, stop here.

2. Was the provider's evaluation and management of the presenting problem significant and beyond normal preoperative and postoperative work?

Yes, an E/M service may be billed with modifier 25.

No, billing an E/M would not be appropriate, stop here.

3. Was the procedure or service scheduled in advance of the patient encounter?

Yes, billing an E/M service would not be medically necessary unless the patient has other medical concerns or problems that the provider addressed, stop here.

No, you can bill both the procedure and the E/M service with modifier 25.

4. Is there more than one diagnosis present that the provider addressed and/or affecting the treatment and outcome?

Yes, you may bill both the procedure and the E/M service with modifier 25, but two or more diagnoses alone do not make it appropriate.

No, depending on medical necessity, you may still be able to report both with modifier 25 if one of the other above factors were met.

Tip: Supporting separate documentation of the E/M service and the procedure is helpful when justifying the E/M-25 service. Don't bury the E/M documentation in the procedure note.