If an E/M service code (99201-99350) is reported in addition to a code from the 99381-99397 and/or 99401-99412 series, modifier 25, Significant, separately identifiable E/M by the same physician on the same day of the procedure or other service, should be appended to the appropriate level E/M service code. Modifier 25 is reported to indicate that on the day a procedure or service identified by a CPT code was performed, the patient’s condition required a significant and separately identifiable E/M service above and beyond the other service provided. Documentation should justify a significant, separately identifiable E/M service for the respective E/M level along with the said code 99406.
But, trigger point injection 20550 has also been performed, for which we can also use modifier 25 with 99406.
Sanjit K Mishra, CPC
SuperCoder.