Q&A: Reporting separately payable E/M services with modifier -25

Q: A patient with a history of hypertension and high cholesterol visits a cardiologist for an appointment, complaining of occasional chest discomfort during exercise. After the physician completes an office visit, it is determined that the patient needs a cardiovascular stress test, which is performed that day by the same physician. Would it be appropriate to report an E/M code for the visit with modifier -25 (significant, separately identifiable E/M service provided by the same physician on the same day of the procedure)?

A: Yes. The physician should report an E/M visit code (99201–99215) with modifier -25 to indicate that a separately identifiable E/M service was performed on the same day as the stress test. He or she would also report CPT code 93015 (cardiovascular stress test using maximal or submaximal treadmill or bicycle exercise, continuous electrocardiographic monitoring, and/or pharmacological stress; with supervision, interpretation, and report) for the stress test.

In general, Medicare considers E/M services provided on the day of a procedure to be part of the work of that procedure. The exception is when the E/M documentation supports that there has been a significant amount of additional work above and beyond what the physician would normally provide and when the visit can stand alone as a medically necessary, billable service.

Documentation to support the use of modifier -25 must clearly demonstrate that:

• The key components of the appropriately selected E/M service were actually performed and address the presenting complaint.
• The physician performed extra work that went above and beyond the typical work associated with the procedure code.
• The purpose of the visit was other than evaluating and/or obtaining information needed to perform the procedure.

When reviewing the physician’s documentation, the carrier should be able to determine that both the E/M visit and procedural service were medically necessary.

Editor’s note: This question was answered by Alicia Shickle, AHFI, CHC, CPCO, CPC, CPMA, CPPM, CRC, during the DecisionHealth webinar, “Avoid Mistakes with Modifiers -25 and -59: As Practices Rebound, Maintain Your Earned Revenue.”

This answer was provided based on limited information. Be sure to review all documentation specific to your own individual scenario before determining appropriate code assignment.