March 2018

Topic: Billing separately identifiable E/M services at the same encounter as a minor procedure

ISMS is committed to helping members who experience difficulties with payer policies and procedures. The purpose of this Issue Brief is to provide information to assist physicians in understanding how to properly code and document evaluation and management (E/M) services provided on the same day as a procedure.

In most cases, these claims are billable and payable by third party payers when (a) such a claim is properly developed and submitted identifying the Current Procedural Terminology (CPT®) code for the procedure performed and the CPT code for the level of E/M service being provided, and (b) the E/M service is modified with the CPT modifier -25.

This policy seems consistent with the guidance provided by the AMA in its 2018 CPT® Professional Edition handbook, which defines modifier -25 as a "significant, separately identifiable service by the same physician or other qualified health care professional on the same day as a procedure or other service." CPT notes that it may be necessary to indicate that on the day a procedure is performed, the patient’s condition required a significant and separately identifiable evaluation and management service above and beyond the scheduled service performed, or beyond the usual preoperative or post-operative care usually associated with the procedure provided.

As with most other claims, these claims may be subject to medical review by payers. However, it is essential that both the procedure and the E/M be properly documented and clearly demonstrate the separate, significant and distinct nature of the E/M service such that it is unrelated to any work component of the procedure being performed at the same encounter.

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