The only answer I can tell you is: it depends on the scenario.
In a nutshell, if the exam leads to the decision for the surgical procedure - yes, modifier 25 on the E/M is appropriate. The procedure must be unplanned. You can usually tell by looking at a prior encounter or notes.
Sometimes I find the decision for the procedure in a copy of a call-back note: "tell pt. to come in for knee joint injection." This is when an E/M is *not* appropriate. The doc already knew that an injection was going to happen prior to the patient's arrival.
A good physician will do a minor exam to determine that the procedure is required. They need to make sure of the location and need for the procedure still exists. Some physicians will do a minor H&P as well to make sure that the patient is healthy enough for the exam. I've seen some cases where the patient was scheduled to come in for a joint injection, but because they were sick, the doctor did a minor exam and sent them home or to another MD without doing the injection. In this case, E/M is appropriate, but not the surgical procedure. Modifiers not required.
One final scenario, and I've seen this too. A patient will present for a pre-planned knee joint injection. First thought/glance - no E/M because they already knew. However, in the course of the mini-exam, patient says, oh, btw, I was playing ball last Tuesday, heard a pop and now my shoulder hurts, what's wrong with me?
Now the doc turns his attention from the knee and examines the shoulder, orders shoulder x-rays, and determines that the patient has a shoulder sprain and needs a sling. Then, his attention goes back to the knee and an injection is performed.
This is a separately identifiable history, exam and MDM that is above & beyond the procedure he's doing for the knee, is documented and this follows the guideline for when modifier 25 is appropriate to use on an E/M with a minor surgical procedure.
It's also a very good reason why coders need to have access to these records and need to read all the way through the notes (as many as it takes) to determine exactly what happened and if it's right to code out the E/M with modifier 25.
Hope this helps you out.
Leslie Johnson, CPC
- ICD-10 Trainings
- Comprehensive Courses
- CPC (Certified Professional Coder)
- COC (Certified Outpatient Coder)
- CIC (Certified Inpatient Coder) NEW!
- CRC (Certified Risk Adjustment Coder) NEW!
- CPB (Certified Professional Biller)
- CPMA (Certified Professional Medical Auditor)
- CDEO (Certified Documentation Expert – Outpatient) NEW!
- CPPM (Certified Physician Practice Manager)
- CPCO (Certified Professional Compliance Officer)
- VIEW ALL CERTIFICATIONS
Coding / Billing Solutions
- Audit / Compliance Solutions
Job Experience / Apprentice Removal
News / Discussion
- Other Resources
- Book Store
- Log In / Join