‘The Physician Talked to the Patient’ Is Not Enough for Modifier 25
Question: An established patient presents for a diagnostic procedure. Before the procedure begins, the physician briefly discusses the patient’s blood pressure and asks whether the patient has taken a prescribed medication, which I was going to report with 99213. Can I code this as a separate evaluation and management (E/M) service with modifier 25 appended, in addition to the procedure? Rhode Island Subscriber Answer: The brief conversation about medication compliance does not, by itself, establish a significant, separately identifiable 99213 (Office or other outpatient visit for the evaluation and management of an established patient, which requires a medically appropriate history and/or examination and low level of medical decision making. When using total time on the date of the encounter for code selection, 20 minutes must be met or exceeded.) E/M service. Coders need documentation showing that the physician performed a substantive E/M service beyond the work inherent in the diagnostic procedure. Simply speaking with the patient before a procedure does not automatically support a separate 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. The claim would be particularly vulnerable if the documentation contained no separately identifiable history, examination, medical decision making, assessment, or other E/M work beyond what the physician performed as part of the cardiac testing. You should not equate patient interaction with a separately reportable E/M service. Before reporting a separate E/M with modifier 25, determine whether the physician performed and documented a significant, separately identifiable E/M service on the same date as the procedure. If the documentation does not support that distinction, reporting 99213-25 in addition to the respective procedure code could result in an avoidable denial or audit finding. Suzanne Burmeister, BA, MPhil, Medical Writer and Editor
