“I have a very specific question about a new patient visit. Here is what my billing company said in a recent email about that for 2026:
‘You can bill a new patient visit with the procedure if you are noting that something completely different than the procedure was discussed. They are just saying that they will no longer pay an E/M code with a procedure if you just spent extra time with the patient on the procedure or if you are going over patient history. They no longer feel that is payable. Which is unfair due to the time each provider spends with a new patient. But that is our reality.
They are saying that if you are seeing a new patient and doing a procedure you cannot just bill for a new patient visit just because they are new. You can bill an E/M code if you feel it’s warranted. Many carriers will likely deny, and we will then appeal it for you. If you are not discussing anything with that patient other than the procedure or history, then it’s up to you if you bill for the new patient visit alone or the procedure alone. Completely up to you.’
Please help us sort this out as I cannot find specific information on this. Do we bill a new patient visit with procedures as always with detailed documentation, or must we pick one or the other?”
E/M Services
1. E/M is NOT a synonym for an office visit.
2. It is a 2-part process:
a. “E” stands for EVALUATION. Using a Medically Appropriate History and/or Examination and *Medical Decision Making, you formulate a WORKING DIAGNOSIS. This shows MEDICAL NECESSITY.
b. “M” stands for management. Using the working diagnosis, you now have to do something about it. In other words, you have to TREAT THE PROBLEM. Diagnosing a problem is not sufficient.
3. *Total Time can be used in lieu of Medical Decision Making in order to determine the most appropriate level of E/M service as long as the total time is appropriately documented within the medical record for the date of service in question.
- And, if that is not enough,
4. ALL CPT (Procedure) codes have an inherent E/M component.
5. In order to bill an E/M service and a CPT code on the same date of service, whether it is an initial encounter or a subsequent encounter, you must through your documentation demonstrate the thought process that was used to extract the E/M component from the CPT code to make the E/M service significant and separately identifiable.
6. You can NEVER, EVER bill an E/M code in lieu of the appropriate CPT code.
Proper Use of the 25 Modifier
- Modifier 25 is used to report a significant, separately identifiable evaluation and management (E/M) service performed by the same physician on the same day as another procedure or service.
- Proper use ensures reimbursement for extra clinical work that exceeds the typical pre- and post-operative care inherent in a procedure.
When to Use Modifier 25
- Significant and Separate: The E/M service must be "above and beyond" the work usually associated with the procedure itself.
- Same Day, Same Provider: It only applies when both the E/M and the procedure are performed by the same professional (or someone in the same specialty/group) on the same date.
- Minor Procedures: Typically appended to E/M codes when performed alongside "minor" procedures (those with 0- or 10-day global periods) like injections, debridements, or biopsies.
- Same or Different Diagnosis: A different diagnosis is not required, though it can help clarify the need for separate billing. The E/M may be prompted by the same symptom that led to the procedure.
- Preventive + Problem-Oriented: Use it when a patient presents for a preventive wellness visit but an unrelated, significant medical issue is also addressed during that same encounter.
Documentation Requirements
- Chief Complaint: Note any additional complaints beyond the reason for the procedure (e.g., new pain when seeing the doctor for a mole removal).
- Detailed History: Include history of present illness (HPI), comorbidities, and relevant past history.
- Thorough Exam: Document a physical exam that goes beyond what's needed for the procedure.
- Medical Decision Making (MDM): Detail the thought process, risk factors, and complexity of the decisions made.
Appropriate Uses of the 25 Modifier
- The 25 modifier is used to demonstrate that a SIGNIFICANT, SEPARATELY IDENTIFIABLE E/M SERVICE was performed on the SAME day of a MINOR surgical procedure by the SAME physician.
- The 25 modifier is only used on an E/M service.
- An INITIAL E/M service CAN be billed when performed on the SAME date of service as a minor surgical procedure code.
* The diagnosis code for the INITIAL E/M service and the diagnosis code for the minor surgical procedure CAN be the SAME.
- An ESTABLISHED patient E/M code CAN be billed when performed on the same date of service as a minor surgical procedure code.
* The diagnosis code for the established E/M service MUST BE DIFFERENT from the diagnosis code for the minor surgical procedure.
* There can be absolutely, positively NO CORRELATION between the E/M service and the minor surgical procedure.
- If an established patient is seen as having a NEW problem that has never been evaluated for previously (ie. never mentioned, never examined, never treated) and a minor surgical procedure is performed on the SAME date of service, then not only can BOTH the established patient E/M service code AND the minor surgical procedure code be billed for, but the diagnosis code for the E/M service and the diagnosis code for the minor surgical procedure can be the SAME.
* Of course, the entire scenario needs to be completely documented in the medical record.
Example of Documentation to Demonstrate a Significant and Separately Identifiable E/M Service (ie. Plantar Fasciitis)
- A medically appropriate history, a medically appropriate examination and medical decision making of low complexity were performed and documented. This supported a significant and separately identifiable E/M service.
- Treatment options/alternatives were discussed with the patient including wearing a firm fitting, supportive sneaker, Rx/OTC orthotics, physical therapy, cortisone injection.
- All questions by the patient were addressed, discussed and answered.
- After a discussion with the patient, it was decided to administer a cortisone injection into the plantar aspect of the right heel at the insertion of the plantar fascia into the calcaneus.
Example of Documentation to Demonstrate a Significant and Separately Identifiable E/M Service (ie. Onychomycosis)
- A medically appropriate history, a medically appropriate examination and medical decision making of low complexity were performed and documented. This supported a significant and separately identifiable E/M service.
- Treatment options/alternatives were discussed with the patient including Rx oral medication, Rx/OTC topical medication, a general treatment plan for onychomycosis: The patient was instructed to keep their feet clean, dry between their toes, change their socks and shoes daily and apply a topical antifungal medication to the affected nails on a regular basis.
- All questions by the patient were addressed, discussed and answered.
- After a discussion with the patient, it was decided to prescribe the patient a topical antifungal medication or provide the patient with an OTC topical antifungal medication..
Common scenarios for its use include
- Routine Foot Care with New Problem: A patient with diabetes presents for routine nail debridement (e.g., CPT 11720) but also reports a new, painful mass on the foot. The podiatrist performs a focused examination and orders x-rays for the mass, which is documented separately from the nail care.
- Acute Issue during Wound Care: During a scheduled follow-up for a Charcot foot wound debridement, the podiatrist discovers and evaluates a new ulcer or infection on the opposite foot or even on the same foot.
- In-Office Injections: A patient presents with heel pain. The podiatrist evaluates the history, performs a physical exam, and decides a corticosteroid injection (e.g., for plantar fasciitis) is necessary. Modifier 25 is appended to the E/M code to ensure payment for the decision-making process separate from the injection procedure itself.
- Preventive and Diagnostic Services: Addressing an acute medical issue such as new joint pain within the 1st MPJ, during a scheduled “At Risk,” Routine Foot Care encounter.
This is my opinion.
Michael G. Warshaw, DPM, CPC
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