Question:
What documentation is needed to support the need for modifier -25 for evaluation and management (E&M) services?
Answer:
Both the medically necessary E&M service and the procedure must be appropriately and sufficiently documented by the physician or qualified non-physician practitioner (NPP) in the patient’s medical record to support the need for modifier -25 on the claim for these services, even though the documentation is not required to be submitted with the claim. For more on this, go to http://www.cms.hhs.gov/mlnmattersarticles/downloads/MM5025.pdf.