You can only use modifier 25 on E/M codes, and you can only report these codes along with a procedure code when “an E/M service is separate and significant from another procedure or service at the same encounter,”
“This does not mean that a different diagnosis is required, but the note must clearly indicate that the E/M dealt with issues that were not part of the other services,”
The most common scenario for reporting an E/M with modifier 25 is one in which you also report a procedure code on the same claim. Before the physician performs any procedure, he will perform some evaluation and management of the patient, including reviewing patient history, explaining the procedure to the patient, answering questions concerning the procedure, obtaining informed consent, etc.
Payers consider this work to be part of the work units associated with the procedure. “Counting any of these items toward a separate E/M service would not be appropriate,” Witt explains.
You should only look for a separate E/M when notes indicate that the patient’s condition required evaluation and management above and beyond the other service provided or beyond the usual pre- and post-procedure care associated with the procedure that was performed. The physician’s notes should include documentation that satisfies the relevant criteria for the respective E/M service that you report. Ideally, those notes should be separate from the notes associated with the procedure, consistent with the “separately identifiable” aspect of modifier 25.
Earn $74 More by Adding Modifier 25
Consider this example, in which the provider performs a J0585 - Injection, onabotulinumtoxina, 1 unit of the TMJ and an E/M service to evaluate the patient’s diabetes and hypertension.
Example: An established patient reports for a scheduled Botox Injection of the TMJ. The patient has also had a history of hypertension and uncontrolled type 2 diabetes. Your clinician performed an expanded problem-focused history and exam of the patient’s hypertension and diabetes and found that hypertension and diabetes will have no adverse effect on the patient’s scheduled procedure. Then, your clinician performed the Injection there is no mention adverse medical condition after performing the injection in the notes.