Evaluation and Management FAQs

Separately Identifiable Service

  1. Please define the appropriate use of modifier 57 to identify a separately payable E/M with an initial decision for surgery.

    Modifier 57 is added to an E/M service that resulted in an initial decision by a surgeon to perform a major surgery (meaning a procedure for which the Medicare Physician Fee Schedule has defined a 90-day global period). This modifier may be added to the E/M service when performed the day before or the day of the major surgery. Services to which modifier 57 are added are not bundled into the surgery payment.
  2. Please define the appropriate use of modifier 25 to identify a distinctly separate service performed on the same date as the E/M service.

    Answer:  Modifier 25 is added to an E/M service when a minor procedure or other service is distinctly separate from the E/M service and the service has been provided on the same date by the same physician. Use of modifier 25 indicates care for a problem or clinical condition that is distinctly separate from the reason for the minor procedure or other service. Check the Medicare National Correct Coding Initiative Edits files to determine the need for modifier 25 on an E/M service.

    A simple means of checking in NCCI: If you enter the code you want to add to the E/M claim in Column 1 (e.g., CPT 93000), you will see in Column 2 all the E/M services that require a modifier 25 if this code is added to the claim. The code will have an NCCI Indicator of 1, meaning it requires addition of modifier 25 to the E/M service.

  3. Please define circumstances in which an E/M service may be separately payable on the same day as a minor surgical procedure.

    Answer: Generally, payment for a minor surgical procedure includes the provider’s decision for the procedure, even when the patient is new to the provider. In occasional circumstances, the provider may perform a significant and separately reportable E/M service with a modifier 25; the diagnoses on the procedure and the E/M may be the same or different. Here are some examples:
  • A separate E/M service is not payable when the patient’s history and examination are straightforward and limited to the presenting problem and the provider’s decision for the minor surgery.
    • For example: A new or established patient presents with knee pain and difficulty in ambulation. The provider’s examination demonstrates osteoarthritis in the knee, supported by X-ray findings, and a decision is made to perform a cortisone injection.
  • A separate E/M service may be payable when the patient’s history and examination reveal findings that require the provider to expand on the course of diagnostic studies or treatments, beyond the injection administered that day.
    • For example: In addition to an assessment of osteoarthritis in the right knee, the provider also notes neurological and/or vascular impairment of the lower leg, or the presence of ulceration. This leads to a concern regarding the patient’s diabetic status and referrals to endocrinology and vascular surgery. In this instance, the provider has expanded the scope of service and was required to perform a separate E/M service based on clinical findings.
  1. Scenario of two MDs in the same practice treating the same patient. The first MD evaluates the patient and makes the decision that the patient would benefit from a joint injection. The patient is referred to another provider in the same practice to perform the injection. Would it be appropriate for the second MD to bill another E/M with the injection?

    If both providers are of the same specialty designation, e.g., orthopedics, only one can bill an E/M service on a single DOS. As a reminder, an E/M service done on the same day as a joint injection requires a separate and distinct scope of service than the injection alone.
  2. Please provide guidelines for a situation in which an office visit can be billed on the same day as chemotherapy.

    The following two examples describe situations in which a separate E/M service (with a modifier 25) may be appropriate:
    1. A patient on chemotherapy is experiencing serious adverse effects, or a new medical condition, requiring full evaluation and reconsideration of dosage and therapy regime. This situation requires key E/M elements such as interval history, examination and medical decision making that may include additional diagnostic testing, and would support a separate E/M service. An example: the beneficiary states he/she developed a 102o fever last night or perhaps developed severe abdominal pain. Either of these could be related to the chemotherapy, but would require an appropriate evaluation.
    2. The patient presents with a swollen and bruised left wrist, having sustained a fall the prior day. The provider examines the patient, orders X-rays and prescribes mild pain medication. This service is distinctly separate from the patient’s scheduled visit for chemotherapy, and may be separately billed.
  3. Please clarify when a podiatrist can bill an E/M visit for a diabetic patient.

    A podiatrist may perform and bill an E/M service for a diabetic patient when the E/M service is for a distinctly separate problem than a procedure scheduled for that date (e.g., diabetic foot care).
  4. How does NGS define an E/M visit for a separately identifiable service?

    An E/M service can be considered separately identifiable when it is performed because of a presenting problem or professional service that is different from the original reason for the patient’s visit.
    • Examples of separately payable E/M services:
      • A patient is seen for routine screening colonoscopy. During the post-procedural discussion, the patient complains to the gastroenterologist about frequent heartburn. The physician performs a limited examination and issues a prescription for Protonix. Addressing the patient's upper GI complaint constitutes a separately payable service.
      • A patient is seen for osteopathic manipulation, but complains of a persistent cough of three days orders a chest X-ray and issues a prescription for antibiotics.
    • Examples of services that are not separately payable:
      • A patient is seen for screening mammography. Prior to the procedure, the patient’s vital signs are recorded and, following the procedure, the physician discusses the results with the patient and requests a breast sonogram. These services are considered to be part of the mammography service, and not separately payable as an E/M service.

Revised 4/17/2024