ED Coding and Reimbursement Alert

Question: One of our physicians is of the belief that he must link any E/M encounter that has modifier 25 appended to it with a different diagnosis code than he has on the procedure. This is sometimes creating incorrect claims. Can you let us know if he is right or not?

Codify Subscriber

Answer: In this case, the physician is incorrect. Sometimes, a patient will require both a procedure and a separate E/M code. As long as you follow the 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) rules, separate diagnosis codes are not necessary.

You must be able to demonstrate medical necessity of both the E/M visit and the procedure, and the documentation should support that. Medicare specifies that the decision to perform a minor procedure in itself is not sufficient justification for an E/M with modifier 25. There must be documentation that the service went beyond the evaluation needed to determine the need for the procedure.

The key to a successful modifier 25 claims is recognizing when your extra work is "significant" and, therefore, additionally billable. While CPT^® does not define "significant," asking yourself the following questions could help you determine whether modifier 25 is appropriate:

• Did you perform and document the key components of a problem-oriented E/M service for the complaint or problem?
• Could the complaint or problem stand alone as a billable service?
• Is there a different diagnosis for this portion of the visit?
• If the diagnosis will be the same, did you perform extra physician work that went above and beyond the typical pre- or postoperative work associated with the procedure code?

If you meet these criteria, you should feel confident reporting the procedure and the E/M with the same diagnosis code when required.