What must the documentation support for an E/M service billed with modifier -25?

For an E/M service billed with modifier -25, the documentation must demonstrate that the service provided was significant and separately identifiable from other services performed on the same day. Modifier -25 is specifically used to indicate that a physician or other qualified healthcare professional performed a significant E/M service above and beyond the other procedures on the same day.

This means that the documentation must clearly reflect that the E/M service was necessary and distinct from any other procedure or service that was performed during that visit. This includes providing evidence such as a detailed history, examination, and medical decision-making that supports the necessity and complexity of the E/M service.

Choosing the correct supporting documentation ensures compliance with coding guidelines and allows for appropriate reimbursement for the service provided. It highlights the physician's work and the need for additional evaluation beyond just the procedure, thereby justifying the use of modifier -25.