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Orthopedic Coding Alert

Take 3 Steps to Fewer Modifier -25 Denials

If you can demonstrate that your E/M encounter and your other procedures are separately identifiable, youll be on the right track to additional reimbursement and fewer denials when using modifier -25.

Modifier -25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) allows separate payment for an E/M service that you perform on the same day as a procedure or other service if you have the documentation to prove it. Follow these three simple steps from the experts to determine whether youve made your case for your modifier -25 claims. 1. Prove That the Service Is Separately Identifiable CMS dictates that all procedures, from simple injections to common diagnostic tests, have an inherent E/M component.

Medicare will not pay you for an additional E/M service unless it is significant and separately identifiable and it goes above and beyond the E/M service you would normally provide as a part of the procedure.

Some practices define significant to mean that the E/M visit must be at least a level-four or -five code (such as 99204 or 99215, Office or other outpatient visit for the evaluation and management ...), but the September 1998 CPT Assistant states, To use modifier -25 correctly, the chosen level of E/M service needs to be supported by adequate documentation for the appropriate level of service, modifier -25 is not restricted to any particular level of E/M service.

So you should append modifier -25 to your E/M code if the physician believes that he or she performed an E/M service that was completely independent of the procedure. I always say, if you dont have an HEM (history, exam, and medical decision-making), you dont have an E/M, says Laureen Jandroep, OTR, CPC, CCS-P CPC-H, CCS, director and senior instructor for the CRN Institute, an online coding certification training center. There should be clear documentation of the HEM, in addition to any notes about procedures performed.

To demonstrate that your E/M service qualifies as an independent evaluation, you should physically separate the E/M notes from the procedure documentation in the medical record. The physician should document the HEM in the patients chart and record the procedure notes on a different sheet attached to the chart. Using this documentation method, a reviewer can clearly identify the two services, each of which is individually supported by documentation. 2. Dont Assume You Need a Separate Diagnosis 
 
The requirement that an E/M service must be separately identifiable is CMS attempt to differentiate E/M services included as part of a larger [...]


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