tci General Surgery Coding Alert - 2010 Issue 10

Coding Basics: Follow 3 Rules to Capture Separate E/M Pay

Avoid modifier 25 scrutiny with proper 'separately identifiable' documentation.Reporting a separate E/M every time your surgeon performs a procedure is asking for an audit. Unlock the secrets to legitimate pay for separately identifiable E/M services using modifier 25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) with these three guidelines.1. Ensure Your General Surgeon Performed a Separate Service You should use modifier 25 when your surgeon's documentation supports that he performed an E/M service that was significant and separately identifiable from the work included...

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