Check Out How Separate Diagnoses Can Result in an E/M-25

Posted on 23 Dec, 2015 |comments_icon 7|By Chris Boucher

Leave E/M-25 off the claim unless you can prove E/M components separate from the procedure.

Coders will need to use modifier 25 on the E/M code when the provider performs a procedure or service, and also treats an entirely different problem with an E/M during the same encounter.

Dilemma: When a patient has a pair of unrelated problems that the provider treats, the claim specifics must reflect the different maladies, confirms Jean Acevedo, LHRM, CPC, CHC, CENTC, president and senior consultant with Acevedo Consulting Incorporated in Delray Beach, Fla. You can often help prove the services were separate by appending different diagnosis codes to each service, when appropriate.

Consider this example, from Marcella Bucknam, CPC, CPC-I, CCS-P, CPC-H, CCS, CPC-P, COBGC, CCC, internal audit manager with PeaceHealth in Vancouver, Wash.  

A patient presents for a follow-up appointment to treat his chronic hypertension and insomnia. The physician documents a detailed history, expanded problem-focused exam and low-complexity medical decision-making. During the encounter, the patient mentions that he has a scaly lesion on his left shoulder. The physician performs a brief history and exam of the lesion, and decides to use cryotherapy to treat the lesion.

See also: Let This Example Guide Your Arthroscopic Injection Coding

Coding: On the claim, you’d report 17000 (Destruction [e.g., laser surgery, electrosurgery, cryosurgery, chemosurgery, surgical curettement], premalignant lesions [e.g., actinic keratosis]; first lesion) for the lesion removal and 99213 (Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: an expanded problem focused history; an expanded problem focused examination; medical decision making of low complexity) for the E/M with modifier 25 (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) appended to show that the lesion removal and E/M for hypertension and insomnia were separate services.

ICD-10 coding: You should append D23.61 (Other benign neoplasm of skin of right upper limb, including shoulder) to 17000 to represent the patient’s lesion, and I10 (Essential [primary] hypertension) and G47.00 (Insomnia, unspecified) to 99213 to represent the patient’s hypertension and insomnia, respectively.

The ‘25 test’: In order to ensure that you are indeed coding for two separate problems, separate the procedure from the E/M in the encounter notes, and then check if you can code for two services. “There should be unique documentation to support each service” in the notes, Acevedo explains.

So if you printed out the encounter note for the above example, and cut out the documentation supporting the shoulder lesion treatment, Acevedo says you should be able to identify all the components of a separate E/M with the remaining documentation.


Chris Boucher

Chris Boucher has nearly 10 years of experience writing various newsletters and other products for The Coding Institute. His blog will cover several areas of coding and compliance, including CPT® coding, modifiers, HIPAA compliance and ICD-10 coding.

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7 thoughts on “Check Out How Separate Diagnoses Can Result in an E/M-25

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