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Medical Record Documentation Providers must document both: The medically necessary E/M service The procedure performed Documentation must support the medical necessity of using Modifier-25 Documentation need not be submitted with the initial claim but should be maintained for potential review Claims Processing Guidelines Current Claims When submitting claims with Modifier-25: Documentation must justify both services E/M service must be separately identifiable Modifier-25 must be appended to the E/M code Prior Claims Carriers will not retroactively recover payments for previously processed claims

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