tci E/M Coding Alert - 2021 Issue Q4

Specialty Spotlight: For Mod 25, Remember The Phrase ‘In Addition To That of The Procedure’

Here’s what your documentation needs to show. Now that coders must select encounter and management (E/M) service codes solely on time spent or medical decision making, many folks may be confused about how and when to append modifier 25 (Significant, separately identifiable evaluation and management service by the same physician or other qualified health care professional on the same day of the procedure or other service). In the past, you could make sure providers included sufficient data in the History and Physical Exam sections so any reviewers could easily see the separate E/M service performed, in addition to...

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