E/M + Procedure = Modifier -25

November 17, 2022

Neon Sign that says "Think about things differently. Differently is upside down

On its face, this doesn’t seem to be a complex matter. But not so fast. There is always more to the story than meets the eye.

First, let’s discuss evaluation and management services. These patient visits are measured, as best they can be, by cognitive work. Second, keep in mind that the relative value unit (RVU) for each minor procedure includes preservice work that may include pre-evaluation time, patient positioning time, and time to scrub and dress before the procedure. There is also E/M time spent post-service, which is also calculated into the minor procedure RVU. Third, how do you know when you can report an E/M service with a minor procedure?

Here are (4) tips to help you decide:

Tip 1: Is this a new patient visit? Yes. New patient visits are automatically excluded from the Global Surgery Package. This means that the new patient E/M visit is paid separately from the procedure.

Tip 2: Is this a scheduled/planned minor procedure? Yes. If the E/M service is NOT related to the minor procedure, you may report a separately identifiable E/M service appending the modifier -25.

Tip 3: Is this a scheduled/planned minor procedure? No. Here is where this can get tricky. If the patient is not new and the minor procedure is not planned, the documentation for the E/M must demonstrate that it is significant and separately identifiable from the minor procedure. Additionally, the E/M service must be medically necessary.

Tip 4:How do you know if the E/M is significant and separately identifiable? If you’re only assessing the specific problem related to the minor procedure, this may be double dipping for the pre-service evaluation work. Your E/M must significantly exceed the pre-service evaluation already paid as part of the minor procedure for it to qualify as significant and separately identifiable. If it doesn’t, only the procedure should be billed. A separate diagnosis is not required.

CMS 2022 NCCI Manual, Ch 1 – General Guidelines, pg. 15:

“If a procedure has a global period of 000 or 010 days, it is defined as a minor surgical procedure. In general, E&M services performed on the same date of service as a minor surgical procedure are included in the payment for the procedure. The decision to perform a minor surgical procedure is included in the payment for the minor surgical procedure and shall not be reported separately as an E&M service.

However, a significant and separately identifiable E&M service unrelated to the decision to perform the minor surgical procedure is separately reportable with modifier 25. The E&M service and minor surgical procedure do not require different diagnoses.

If a minor surgical procedure is performed on a new patient, the same rules for reporting E&M services apply. The fact that the patient is “new” to the provider/supplier is not sufficient alone to justify reporting an E&M service on the same date of service as a minor surgical procedure.

NCCI contains many, but not all, possible edits based on these principles. “

In Summary:

There is conflicting CMS data with regards to New Patient visits and a minor procedure performed on the same day. According to the NCCI tool for the -25 modifier on the Palmetto GBA page, E/M visits that are explicitly for new patients are excluded from the global surgery package. I would say, most often, this is the case. Best practice, let the payer decide if and when your documentation is requested.

As of September 1, 2022, many private payers have been requesting documentation for the E/M service when the -25 modifier is appended and a minor procedure was performed on the same day. Especially for established patients returning for another steroid or trigger point injection.

Good Documentation:

If your E/M service goes above and beyond the pre-and-post service work associated with the minor procedure, make sure the E/M is medically reasonable necessary. In other words, make sure there is good clinical rationale for doing another workup for the established problem related to the minor procedure on the same day.