When reporting both an E&M and procedure code, modifier 25 should be appended to the E&M service. Often, both services are reported when the E&M service involved an initial evaluation of a presenting problem and the decision to perform the procedure was based on that evaluation. Consider a patient who presents for a lumbar epidural steroid injection, but also asks you to evaluate his shoulder pain. In this situation, you would report both the E&M service and the epidural injection code, but you would have different diagnoses. In this instance, each CPT code is linked to the applicable diagnosis code on the claim.
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