An E/M service is considered separate and distinct from a dermatology procedure when the provider performs and documents a significant, separately identifiable evaluation and management service that goes above and beyond the work normally included in the procedure. In these cases, the E/M service may be reported with modifier 25 in addition to the procedure. Importantly, CMS and the AMA state that the E/M service and procedure do not require different diagnosis codes; the same diagnosis may support both services when documentation supports the separate E/M work.
CMS and AMA Guidance
Both the AMA and CMS define modifier 25 as indicating a significant, separately identifiable E/M service performed by the same physician or qualified healthcare professional on the same day as a procedure. The E/M service must be above and beyond the evaluation that is routinely included in the procedure itself and must be supported by the medical record.
A common misconception is that the E/M service and procedure must have different diagnoses. However, AMA and CMS guidance specifically state that the E/M service may be prompted by the same condition for which the procedure is performed. As a result, different diagnosis codes are not required.
Dermatology Example: Actinic Keratosis
A patient presents with multiple actinic keratoses and extensive sun-damaged skin. During the visit, the provider evaluates the extent of disease, reviews prior treatment failures, discusses field therapy options, assesses risks and benefits, and develops a treatment plan that includes prescribing topical fluorouracil (Efudex). The provider also performs cryotherapy on selected actinic keratoses.
In this scenario, the E/M service may be reported with modifier 25 because the evaluation and treatment planning for field therapy represents work that is separate from and above the evaluation typically included in the cryotherapy procedure. The diagnosis code L57.0 (Actinic Keratosis) may be reported for both the E/M service and the cryotherapy when supported by the documentation.
Documentation Essentials
To support a separate E/M service, documentation should clearly demonstrate:
- A medically necessary E/M service beyond the procedure-related assessment. Medical decision-making (or time, when applicable) supporting the reported E/M level.
- Distinct evaluation, counseling, or management activities that exceed the usual pre- and post-procedure work.
- Separate documentation of the procedure performed.
Key Takeaway
The question is not whether a procedure and E/M service occur on the same day, it is whether the provider performed a significant, separately identifiable E/M service that stands on its own. When documentation demonstrates distinct evaluation and management work beyond that included in the dermatology procedure, reporting an E/M service with modifier 25 is appropriate, even when both services are linked to the same diagnosis code.
