EM Coding Alert

Question:

Our physician saw a patient in the office and performed wound care. There was limited history, only vital signs taken, and limited medical decision making documented. The doctor wants me to attach modifier 25 and report both the debridement service and the office visit. Is this okay?

New Jersey Subscriber

Answer:

You cannot simply put a modifier on your E/M visit code to get paid. Make sure your E/M is a significant, separately identifiable service from the minor E/M service that payers associate with the procedure.

CPT^® considers minor procedures to have a very small E/M already included with the procedure. Therefore, insurers won’t pay an E/M unless it is a significant, separately identifiable service. And Medicare will not pay an E/M separately on the same date of service as a procedure if the purpose of the E/M was for the doctor to decide to do the procedure. “The decision to perform a minor surgical procedure is included in the payment for the minor surgical procedure and should not be reported separately as an E/M service. However, a significant and separately identifiable E/M service unrelated to the decision to perform the minor surgical procedure is separately reportable with modifier 25,” according to the National Correct Coding Initiative Policy Manual, Chapter 1.

In other words: If your physician captures minimal history, performs a limited exam, and documents low medical decision making (MDM), all of which are associated with the procedure, the E/M does not qualify for modifier 25. Therefore, you should consider the E/M included in the procedure and you should not separately code for it.

Alternative: Some payers may prefer modifier 57 (Decision for surgery) for E/M services during the global period of any procedure, so check with your payer and get this instruction in writing to keep with your compliance materials.