E/M Services: Answer 'Separate' or 'Inherent' Question Prior To Using Modifier 25

E/M Services: Answer 'Separate' or 'Inherent' Question Prior To Using Modifier 25

When an ophthalmologist carries out an E/M service and a procedure on the same patient during the same encounter, you may or may not be able to report the E/M using modifier 25.

In order to rightfully code an E/M-25, you must prove that the E/M is a separate service and is not an inherent component of the procedure. Follow this advice to find out when to report an E/M with modifier 25, and when to leave the E/M off the claim.

Include evidence of separate E/M in notes

The basics: Medical coders should append modifier 25 when a significant, separately identifiable E/M service is carried out by the same physician at the same face-to-face encounter as a procedure or other service. The most important element on successful 25 claims is concrete evidence that the procedure and E/M were truly separate:

You can only think about reporting modifier 25 when coding an E/M service. All procedure codes have an inherent E/M component and the physician must go beyond that to justify a separate E/M. To add to it, the E/M service must also meet medical necessity criteria. Here's an example: An established patient with dry eye syndrome reports to the ophthalmologist for a scheduled punctal plug insertion. After discussing the procedure with the patient and answering a few questions, the ophthalmologist inserts a collagen plug in the patient's right lower puncta. In this instance, the ophthalmologist does not carry out a significantly separate E/M. The patient reported with a set appointment for the plug insertion and already had a diagnosis. Report the following on the claim: 68761 for the insertion modifier E4 (lower right, eyelid) linked to 68761 to show the location of the plug insertion 375.15 (Tear film insufficiency, unspecified) linked to 68761 to represent the patient's condition. Here's an example: A patient complaining of eye pain reports to the ophthalmologist. The ophthalmologist carries out a review of systems; a check of past, family and social history; and problem-focused exam on the eye, which reveals conjunctival foreign body (FB). The ophthalmologist then removes the FB. In this example, the ophthalmologist carried out an E/M before carrying out the procedure. You should also report the following on the claim: 65205 for the removal, 930.1 linked to 65205 to represent the patient's condition, 99212 for the E/M, modifier 25 linked to 99212 to show that the E/M and plug insertion were separate services, 379.91 linked to 99212 to represent the patient's eye pain. For all evaluation & management guidelines, stay tuned to a medical coding guide like Supercoder.

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