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.
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