Look to Treatment Plan Changes When Considering Modifier 25 for New Patients
Question: An encounter note says a new patient was seen by a primary care physician for complete physical exam performed alongside an evaluation and management (E/M) service. The patient presented with several chronic but stable conditions that require ongoing monitoring and medication review. To ensure these conditions are not progressing, labs and diagnostic imaging were ordered and clearly linked to the relevant problems in the encounter note. Does this qualify for a separate and significant service beyond the regular E/M, due to the patient being new to the provider and the review of multiple chronic conditions and medication refills? AAPC AUDITCON Attendee Answer: If this is a new patient, you’re providing a new patient E/M, which offers a little more flexibility in what’s needed to establish care separate from a physical or wellness exam, in part because there aren’t any National Correct Coding Initiative (NCCI) edits, said Jacob Swartzwelder, CPC, CIC, CRC, CEMC, CPMA, in his AAPC AUDICTCON 2025 presentation “Modifier 25: Medical Necessity & MDM.” If well visits do include ordering tests, studies, or other services that are needed to maintain health, and they do include a review of a patient’s conditions to a degree, then they help constitute a holistic approach to keeping a patient well. “Personally, if there’s a chronic condition review in addition to some sort of wellness exam, that has a thought process and a treatment plan associated with it that has changed or [is] being created, then I’m usually super comfortable with it,” he said. If it is a continuation of a previously considered treatment plan, then the thought process regarding treatment may not really qualify as significant. If there’s a creation of a new treatment plan, then you may be over in 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) territory. Rachel Dorrell, MA, MS, CPC-A, CPPM, Production Editor, AAPC
