tci ED Coding & Reimbursement Alert - 2015 Issue 4

Reader Question: Separate Documentation Key to Correct Modifier 25 Claim Coding

Question:  I am having trouble with my modifier 25 coding, specifically with my documentation to prove a separate evaluation and management (E/M) service. Can you offer any advice on how to document my modifier 25 claims? Montana Subscriber Answer:  When you are coding an encounter in which the physician provides an E/M service and performs another procedure, you should separate the documentation for both services and make sure there are 2 distinct processes. If you follow this documentation advice, it should improve your accuracy on claims containing modifier 25 (Significant, separately identifiable evaluation and management service by...

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