With the new guidelines for office and other outpatient evaluation and management (E/M) code selection not requiring history and examination, how do you determine when an office E/M code is significant and separately identifiable from a procedure performed on the same date?

The good news is that modifier 25 (significant, separately identifiable E/M service by the same physician or other qualified health care professional on the same day of the procedure or other service) is unchanged in 2021. The criteria for use also remain the same.

Despite office E/M (99202–99205, 99212–99215) code selection based on medical decision-making (MDM) or total time on the date of service, the documented history and examination (in addition to MDM) still help provide the clinical indication for and context of a significant and separately identifiable E/M service. Documentation should show that an evaluation and MDM significantly beyond that typical for the preservice...

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