tci E/M Coding Alert - 2018 Issue 5

Reader Question: Document Necessity in This E/M-25 Encounter

Question: Our claim for an evaluation and management (E/M) service and a procedure was audited and then the payer wanted money back, saying we didn't demonstrate medical necessity for the separate E/M service. What are we missing? New Hampshire Subscriber Answer: There is only one way to prove medical necessity for the separate E/M and procedure, and that is to have clear documentation. Typically, you won't submit documentation on your modifier 25 (Significant, separately identifiable evaluation and management service by the same physician or other qualified health care professional on the same day of the procedure or other service)...

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