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Reminder: Use of modifier-25 when reporting E&M services with spinal/extraspinal manipulation codes

December 29, 2011

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This is a reminder regarding the reporting of Evaluation & Management (E&M) services along with spinal/extraspinal manipulation codes. The chiropractic manipulation treatment codes include a pre-manipulation patient assessment. Therefore, E&M services are not eligible for separate reimbursement when provided in conjunction with chiropractic spinal manipulation, with the following exceptions:

  • when the initial E&M is for a new patient. A new patient is one who has not received any professional services from the physician, or another physician of the same specialty who belongs to the same group practice, within the past three years.
  • when the E&M service is provided for an established patient with an acute exacerbation of symptoms or a significant change in condition, or the E&M service is performed for a condition distinct from that of the chiropractic spinal manipulation. Providers should append modifier -25 (significant, separately identifiable E&M service by the same physician on the same day of the procedure or other service) to the appropriate E&M procedure code to indicate that a separate service has been performed.

When E&M services are provided, the level of the E&M reported must reflect the appropriate level of service performed and must be documented in the individual?s medical record. Routine use of E&M services without justification and reporting E&M services when other services are being performed is not an appropriate billing practice and is subject to post-payment review.

For additional information on the appropriate reporting of modifier -25 with an E&M code and the reporting of spinal/extraspinal manipulation codes with E&M, see Claim Payment #03.00.06h (Modifier 25: Significant, Separately Identifiable Evaluation and Management Service by the Same Physician on the Day of a Procedure or Other Service) and Medical Policy #10.02.02e Chiropractic Spinal and Extraspinal Manipulation Therapy). These policies are available on our website at www.ibx.com/medpolicy.

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