Radiology Coding Alert

You know that you should append modifier 25 to a visit only when the radiologist’s documentation supports a significant and separate service. CPT Codes 2006, however, will reinforce this guideline.

The update will clarify the explanatory text for  modifier 25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service). The new explanation will state that a “significant, separately identifiable E/M service” should have documentation that meets the requirements for the E/M service being reported.

This solidifies most coding experts’ recommendations that you should be able to lift the E/M documentation from your notes and it should stand as a completely separate service from what the radiologist performed during the procedure or service.