tci General Surgery Coding Alert - 2007 Issue 10

Reader Question ~ Separate Documentation Keys Modifier 25 Coding

Question: I am having trouble with my modifier 25 coding, specifically with my documentation to prove a separate E/M service. What documentation should I look for to report modifier 25?Montana Subscriber Answer: When you are coding an encounter during which the physician provides an E/M service and performs another procedure, you should separate the documentation  and make sure there are two distinct processes. If you follow this documentation advice, your accuracy should improve on claims containing modifier 25 (Significant, separately identifiable E/M service by the same physician on the same day of the procedure or other service).When...

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