Pulmonology Coding Alert

Question:

Indiana Subscriber

Per CPT, you don't need to use a different diagnosis code in order to use modifier 25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service). Attaching different diagnosis codes to the E/M and the procedure does assist in supporting separately reason for each service, when applicable. Additionally, it demonstrates the true clinical rationale for each service, when applicable. Your key to separately reporting the E/M service lies in whether your doctor performed and documented work beyond what is considered to be part of the procedure.

In short, when using modifier 25, the diagnosis associated with the E/M service can be the same as or different from the diagnosis associated with the same-day procedure. The CPT manual description of modifier 25 states: "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."

Key: Your pulmonologist's documentation should clearly establish that the E/M involved work over and above that typically associated with the procedure, and that the encounter's sole purpose was not to perform the procedure.