spent on the E&M with your patient. Separately distinguishable requires a procedure be performed in addition to the E&M service on the same day that was not mandated by the evaluation and management itself.
Per CMS guidelines, both the medically necessary E/M service and the performed procedure must be substantiated by the physician or qualified NPP in the patient’s medical record to support the need for the Modifier 25 on the claim. The documentation is not required to be submitted with the claim, but it could be subsequently requested by the patient’s insurance. For this reason alone, document, document, document.
Almost all providers bill for the evaluation and management services of new patients. Choose the proper E&M service code by determining your patient’s status on the date of service, new or established, the place of service the E&M is performed in, and the level of the service provided to your patient.
Proper use of modifier 25 comes into play with both new and established patient E&M services. An established patient E&M service is applicable with a newly presented diagnosis. The procedure performed can substantiate the need for an evaluation and management of your patient. In either determination, the 25 modifier is only applicable when in addition to a procedure performed the same day by the same qualified practitioner.
Remember, separately identifiable is the key. If your services to the patient did not include a procedure outside of the completed evaluation and management, you would NOT apply the modifier 25 to the E&M CPT on your insurance claim. The modifier 25 will NEVER be used on any reporting codes, procedures or any services other than E&M services. However, it is not to be mistakenly used on EVERY evaluation and management procedure you bill.