Gastroenterology Coding: Go Easy With Your Modifier 25 Use

By Author: erinarticle
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Don't be too hard on your modifier 25 use


A certain doctor in our clinic said you don't require different diagnosis codes to use modifier 25 for reporting an evaluation & management service on the same date as a procedure. But then I have always added modifier 25 to the evaluation & management when I bill more than one procedure, pointing the primary diagnosis to the evaluation/management and a secondary diagnosis to the other procedure. How should one go about this situation?


Well, you do not need to use a different diagnosis code in order to use modifier 25 (Significant, separately identifiable evaluation & management (E/M) service by the same doctor on the same day of the procedure or other service). Attaching the different diagnosis codes to the evaluation & management and the procedure does not necessarily support a separately reportable evaluation & management service. Your key to separately reporting the E/M service lies in whether your physician carried out and documented work beyond what's thought of as part of the procedure.


In a nutshell, ...
... while using modifier 25, the diagnosis associated with the evaluation & management service can be the same or different from the diagnosis associated with the same-day procedure. According to the CPT manual description of modifier 25, "The evaluation & management service may be prompted by the symptom or condition for which the procedure and/or service was given. Therefore, different diagnoses aren't required for reporting of the evaluation and management on the same date."


Important: Your gastroenterologist's documentation should establish clearly that the evaluation & management involved work over and above that normally associated with the procedure, and the encounter's only purpose was not to carry out the procedure.


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