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Thread: Separate Documentation for Procedure

  1. #1
    Join Date
    Apr 2007

    Default Separate Documentation for Procedure

    AAPC: Back to School
    I am looking for some sort of reference that confirms the need to complete a SEPARATE procedure note when billing and E/M code w/ 25 modifier plus a procedure code on the same date of service.
    Patient seen for ENT eval coded 99203 - 25 AND has a flexible bronch and coded 31575.

    My provider(s) are adamant that they can bill as above and have the procedure note be within the E/M note for the visit.
    My understanding that if you are billing for a "significant and separately identifiable procedure " that you need a "separately identifiable" note.

    Seeing is believing so I am looking for some help on this; I of course have the text from the Modifier description in the CPT book, anything else out there?

    Thanks in advance!

  2. #2


    In seminars I have always heard that it is a "best practice" to have a separate note but I have never seen anything official in writing. For our Docs as long as it is in the note somewhere it is allowed. We have Highmark and here is there stand from their FAQ's. How does Highmark Medicare Services review Evaluation and Management Services (E/Ms) billed with the -25 modifier?
    Modifier -25 is defined as a significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service. In the review of E/M services billed with the -25 modifier, Highmark Medicare Services will first identify within the medical records the documentation specific to the procedure or service performed on that date of service. Next, we will consider the additional documentation separate from the documentation specific to the procedure or service to determine:
    o If there is a significant, separately identifiable E/M service that was rendered and documented, and
    o If the required components of the E/M service are supported as "reasonable and necessary" per Social Security Act, Section 1862(a)(1)(A), and
    o What level of care is supported by the documentation.

    I hope this helps.
    Pat Crist, RHIT, CCS-P, CPC, CHCAF

  3. #3
    Join Date
    Apr 2007
    Milwaukee WI

    Default Significant Separately Identifiable E/M

    Without seeing the actual documentation I cannot tell whether you have a legitimate "significant, separately identifiable E/M." In general ...

    If the patient was scheduled for the procedure, then there is no significant, separatley identifable E/M performed (unless there is something totally unrelated ... e.g. otitis media or rash on arm).

    If the patient was scheduled for evaluation and as a result of that evaluation/exam the decision was made to perform a diagnostic bronchoscopy, then you may have a significant, separately identifiable E/M service.

    There is NO need to have a completely separate procedure note; but the procedure has to be clearly documented separately from the E/M service. We are not using an EMR, so our physicians dictate their clinic notes. When they perform a procedure on the same date as an E/M they will usually dictate a separate paragraph titled: PROCEDURE NOTE at the end of their E/M dictation. It all becomes one document, with one signature and date of service.

    Hope that helps.

    F Tessa Bartels, CPC, CEMC

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