Significant, Separately Identifiable Evaluation and Management Service by the Same
Physician or Other Qualified Health Care Professional on the Same Day of the
Procedure or Other Service: It may be necessary to indicate that on the day a
procedure or service identified by a CPT code was performed,
the patient's condition required a significant, separately identifiable E/M service above and beyond the other service provided or be beyond the usual preoperative and postoperative care associated with the procedure that was performed. A
significant, separately identifiable E/M service is defined or substantiated by documentation that satisfies the relevant criteria for the respective E/M service to be reported (see Evaluation and Management Services Guidelines for instructions on determining level of E/M service). 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. This circumstance may be reported by adding modifier 25 to the appropriate level of E/M service. Note: This modifier is not used to report an E/M service that resulted in a decision to perform major surgery. See modifier 57. For
significant, separately identifiable non-E/M services, see modifier 59.