Practice Management Alert

There are three basic conditions under which an E/M service might qualify for a 25 modifier:

1. You have a different diagnosis for the E/M and the procedure. The two diagnoses may be related -- such as when the diagnosis with the E/M is a sign or symptom and the diagnosis with the procedure more definitive. In this case, the E/M resulted in a decision to perform the procedure, either diagnostic or therapeutic.

2. The second condition is similar, except on doing the procedure, there is no second diagnosis. Medicare specifically states that there is no requirement for separate and distinct diagnoses for the E/M with a 25 modifier and the procedure. So, for example, you may have a sign and symptom for the E/M. Then, the diagnostic minor procedure results in no definitive finding, so the sign or symptom would also be related to the minor procedure. The E/M still, as described above, was a decision to perform the minor procedure.

3. The "oh by the way" scenario, where the patient comes in for one problem (the E/M) and before the patient is finished with the physician, she states, "oh by the way, can you look at my ..." If this request results in the performance of a minor procedure which is totally unrelated to the original reason for the visit, the diagnosis on the E/M and the minor procedure are totally unrelated.