Primary Care Coding Alert

Answer: Modifier -25 was established to report a significant, separately identifiable evaluation and management (E/M) service by the same physician on the same day of another procedure, as defined by CPT guidelines: The E/M service may be prompted by the symptom or condition for which the procedure and/or service was provided. As such, different diagnoses are not required for reporting of the E/M services on the same date.

In this case, BCBS is correct. An E/M service for the initial evaluation of the patient may have been reported in addition to the code(s) for other services provided. Modifier -25 is attached to the E/M visit. For example, the patient presents with a laceration of the scalp (873.0) he received in a fall. The physician performs an expanded problem-focused exam of the patient to make sure that the fall has not caused other musculoskeletal and/or neurological problems. Therefore, the appropriate level E/M code with a -25 modifier would be reported, along with 12002 (simple repair of superficial wounds of scalp, neck, axillae, external genitalia, trunk and/or extremities [including hands and feet]; 2.6 cm to 7.5 cm) and 90703 (tetanus toxoid absorbed, for intramuscular or jet injection use).

Coders should be aware, however, that you cannot always bill an E/M visit with laceration repair because a basic evaluation of the laceration for foreign body, etc., is considered part of the repair code. All CPT and Medicare guidelines state a significant level of service must be performed that is separately identifiable from the performance of the procedure. Medicare offers the example of E/M with head injury because the performance of a neurological exam is not a component of laceration repair, but also says that verifying that a hand laceration is clean and tetanus is needed would not justify the significant level of service required to bill modifier -25. Therefore in instances like these, both the E/M and the repair codes would not be reported.