tci ED Coding & Reimbursement Alert - 2011 Issue 7

Documentation: Prove Service's Separate Nature Before Coding E/M-25

Modifier 25 used most often on separate ED E/Ms.When your ED physician performs a procedure, a separate E/M service is common.Red flag: A separate E/M is not a given, even in the ED. If your ED physician performs an E/M service and a procedure on the same patient during the same encounter, you might be able to report the E/M using modifier 25 (Significant, separately identifiable E/M service by the same physician on the same day of the procedure or other service).The key: You must prove that the E/M is a separate service and is not...

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