You should stop omitting modifier 25 because of same day diagnosis.
Recently, someone told me that we do not require different diagnosis codes to use modifier 25 for reporting an Evaluation & management service on the same date as a procedure. However, I have been told many times in the past by certified coders that when I bill more than a procedure that I need to add modifier 25 to the evaluation & management and point the primary diagnosis to the evaluation & management and point a secondary diagnosis to the other procedure. Can you help clear up my doubt?
Answer: Proper modifier 25 use doesn't need a different diagnosis code. As a matter of fact, the presence of different diagnosis codes attached to the E/M and the procedure doesn't support a separately reportable E/M service.Your key to reporting the E/M service lies in whether your doctor carried out and documented work beyond what's considered to be part of the procedure.
How if functions: The information about modifier 25 in the CPT manual distinctly indicates that you don't need to have two different diagnosis codes to use the modifier. As per the CPT manual description of modifier 25, the evaluation & management service may be prompted by the symptom or condition for which the procedure and/or service was provided. Therefore, different diagnoses are not required for reporting of the E/M services on the same date."
Both CPT and Medicare rules will allow the same diagnosis for the evaluation & management service with modifier 25 and the procedure on the same day, and Medicare will pay for both with the same diagnosis, assuming both are reasonable and necessary and otherwise meet Medicare coverage criteria. The catch is that your physician's documentation should establish clearly that the evaluation & management involved work over and above that typically associated with the procedure done at the same encounter and that the encounter's sole intention was not to carry out the procedure. So if you get denials on modifier 25 claims just because you use the same diagnosis code for the Evaluation & management and the procedure, you should appeal, assuming your physician's documentation supports reporting separate services.
Recently, someone told me that we do not require different diagnosis codes to use modifier 25 for reporting an Evaluation & management service on the same date as a procedure. However, I have been told many times in the past by certified coders that when I bill more than a procedure that I need to add modifier 25 to the evaluation & management and point the primary diagnosis to the evaluation & management and point a secondary diagnosis to the other procedure. Can you help clear up my doubt?
Answer: Proper modifier 25 use doesn't need a different diagnosis code. As a matter of fact, the presence of different diagnosis codes attached to the E/M and the procedure doesn't support a separately reportable E/M service.Your key to reporting the E/M service lies in whether your doctor carried out and documented work beyond what's considered to be part of the procedure.
How if functions: The information about modifier 25 in the CPT manual distinctly indicates that you don't need to have two different diagnosis codes to use the modifier. As per the CPT manual description of modifier 25, the evaluation & management service may be prompted by the symptom or condition for which the procedure and/or service was provided. Therefore, different diagnoses are not required for reporting of the E/M services on the same date."
Both CPT and Medicare rules will allow the same diagnosis for the evaluation & management service with modifier 25 and the procedure on the same day, and Medicare will pay for both with the same diagnosis, assuming both are reasonable and necessary and otherwise meet Medicare coverage criteria. The catch is that your physician's documentation should establish clearly that the evaluation & management involved work over and above that typically associated with the procedure done at the same encounter and that the encounter's sole intention was not to carry out the procedure. So if you get denials on modifier 25 claims just because you use the same diagnosis code for the Evaluation & management and the procedure, you should appeal, assuming your physician's documentation supports reporting separate services.
