E/m and modifier 25


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I'm from Wiscosin and our practice has come across a bundling issue. The insurance companies are bundling injections, venipunctures, x-rays done on the same day unless the 25 modifier is applied to the E/M code. My understanding of the 25 modifier is that if you do a "proceedure" on the same day the 25 modifier must used on the visit if separatly identifiable service or decision made at visit for minor proceedure. Your input on this would be greatly appreciated.
A 25 mod modifier must be added to the E/M when done on the same day as injections or other procedures.
The definition of modifier 25—significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service—was clarified in 2008.
This will clarify it for you:
Modifier 25 is used to indicate that, on the day a procedure or service identified by a CPT code was performed, the patient's condition required a significant, separately identifiable E&M service above and beyond the other service provided or beyond the usual preoperative and postoperative care associated with the procedure that was performed.

Documentation must define or substantiate the significant, separately identifiable E&M service. The E&M service may be prompted by the symptom or condition for which the procedure and/or service was provided. As such, different diagnoses are not required for reporting the E&M service on the same date. This circumstance may be reported by adding modifier 25 to the appropriate level of E&M services.

Modifier 25 should not be used to report an E&M service that resulted in a decision to perform surgery; modifier 57 should be used in this specific setting. Modifier 59, which will be discussed more fully next month, should be used for significant, separately identifiable non-E&M services.
E/M level with Procedure

I code ED physician services. It is my understanding that you can't use the same history, exam and MDM elements to support an E/M level that are inheirent in the service for a procedure done the same day For example: a patient is treated in the ED for laceration repair to scalp but the patient also has cerebral hemorrage and complete work-up is done. I find it difficult to determine which elements I can use to determine the E/M level that are not included in the elements for the procedure. Can anyone point me to some guidelines? Thank you.