Evaluation and Management Services Coding Questions

Is modifier 25 reported on the second encounter if a physician sees a patient in the office in the morning and again in the afternoon for a new or worsened condition?

No, modifier 25 is used to identify a significantly, separately identifiable E/M service performed by a physician on the same date as a procedure or other service. Medicare would not expect to see two E/M services reported on the same date on a routine basis. The physician would be expected to combine the documentation and bill only one E/M.

In rare circumstances, would a physician bill a second E/M service on the same date of service for the same patient?

If a second E/M service is required on the same date of service, the documentation should clearly provide evidence of the second E/M service occurring, the reason for the additional E/M service, and documentation of the medical necessity of the second E/M service. When reporting a second E/M service on the same date, the service will initially deny. You can appeal the denial with documentation.

How does Medicare review an E/M billed with modifier -25?

Modifier -25 is used to report significant and separately identifiable E/M services by the same physician on the same day of the procedure or other service. In the review of E/M services billed with the -25 modifier, Medicare will first identify within the medical records the documentation specific to the procedure or service performed on that date of service. We also consider the additional documentation separate from the documentation specific to the procedure or service to determine:

If there is a significant, separately identifiable E/M service that was rendered and documented, and If the required components of the E/M service are supported as "reasonable and necessary" per Social Security Act, Section 1862(a)(1)(A), and What level of care is supported by the documentation?

Can two physicians in the same group practice, who see the same patient on the same day, each bill for an E/M service and receive payment?

Physicians in the same group practice but who are in different specialties may bill and be paid separately without regard to their membership in the same group. Physicians in the same group practice who are in the same specialty must bill and be paid as though they were a single physician. If more than one evaluation and management (face-to-face) service is provided on the same day to the same patient by the same physician or more than one physician in the same specialty in the same group, only one evaluation and management service may be reported unless the evaluation and management services are for unrelated problems. Instead of billing separately, the physicians should select a level of service representative of the combined visits and submit the appropriate code for that level.

Reference: CMS Publication 100-04, Claims Processing Manual, Chapter 12, Section 30.6.5

How is the AI modifier used?

The principal physician of record appends modifier “-AI” to the initial hospital care visit code when billed to identify the principal physician of record. This modifier identifies the physician who oversees the patient’s care from all other physicians who may be furnishing specialty care. All other physicians who perform an initial evaluation on this patient bill without the "-AI" to indicate specialty care. This modifier is informational only. It does not affect payment. Claims which include the “-AI” modifier on codes other than the initial hospital and nursing home visit codes (i.e., subsequent care codes or outpatient codes) will not be rejected and returned to the physician or provider.

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