KNOW THE BASICS
Use modifier 25 (Significant, separately identifiable evaluation and management service by the same physician or other qualified healthcare professional on the day of the procedure or other service) to identify when a patient has a separate E/M service along with a procedure or other service on the same day by the same physician. You can submit a separately identifiable E/M service code and modifier only if the documentation meets specific criteria. When the documentation clearly and distinctly proves that a significant and separately identifiable service was done, you may report modifier 25 with the E/M code (not the procedure code) to tell the patient’s insurance they need to pay for both services.
Payers do not always clearly define what constitutes significant and separately identifiable work. In general, however, documentation that supports a separate E/M service must include proof that the service is:
The patient’s symptoms or condition often justify a separate E/M service. Payers all typically recognize and allow you to report an E/M service on the same day of a procedure when the documentation shows that the E/M service is for a condition unrelated to the procedure. Payers generally also allow you to report two E/M visits when the provider addresses more than one problem, and each problem involves separate HEMs as long as each problem requires a medically necessary service. Payers differ, however, in their recognition and reimbursement policies for modifier 25, so check with your individual payers for guidance.
Medicare has specific guidance for when you can report a significant and separate E/M visit. When billing Medicare, you can report a separate E/M visit when:
TIP: Have your provider write or dictate her notes so that documentation for the separate E/M service is clearly separate from documentation for the other services or procedures. This can simply be the physician stating or writing a header such as “A significant and separate E/M service was necessary for …” This separate documentation for the E/M-25 problem is especially helpful for denial appeals as it allows you to easily highlight supporting evidence.
Learn more about modifier 25—and all the CPT® modifiers with TCI’s Modifiers Explained 2018.