Coding Corner: Separately billing in E/M visits

October 01, 2012
Area(s) of Interest: Emergency Services Hospitals and Health Facilities Payor Issues and Reimbursement Practice Management 

CPR’s “Coding Corner” focuses on coding, compliance, and documentation issues relating specifically to physician billing. This month’s tip comes from AAPC’s G. John Verhovshek, MA, CPC.

Under both the Center for Medicare & Medicaid Services (CMS) and CPT® guidelines, an Evaluation and Management (E/M) service may be separately billed with a minor procedure as long as the E/M service was clearly documented and substantiated and modifier 25—Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service—is properly appended to the appropriate E/M service code.

CMS transmittal R954CP (Medlearn Matters number: MM5025, change request (CR) 5025) instructs coders to apply modifier 25 for “a significant, separately identifiable E/M service that is above and beyond the usual pre- and post-operative work for the service,” and to “appropriately and sufficiently” document medical necessity for both the E/M service and the other service or procedure.

Both the procedure and the separate, same-day E/M service must be linked to an approved diagnosis, substantiated in the medical record. The diagnoses supporting each service may be the same or different. Per transmittal R954CP, “The E/M service may be prompted by the symptom or condition for which the procedure and/or service was provided. As such, different diagnoses are not required for reporting of the E/M services on the same date” [emphasis added].

The American Medical Association (AMA) guidelines, as outlined in the CPT® codebook and CPT® Assistant, also clearly and consistently support coding for a minor procedure and a separate, significant same-day E/M with modifier 25. Below are three such examples from CPT® Assistant, involving varying specialties and spanning nearly 20 years.

Example 1 (Winter 1993, CPT® Assistant):

…a physician examines a patient with a fever, headache, vomiting and stiff neck. A spinal tap is performed as well as the services described in code 99214. The -25 modifier is appended to code 99214 to indicate that both a significant E/M service and a procedure were performed on a given day.

Example 2 (May 2003, CPT® Assistant):

A physician examines a new patient exhibiting symptoms of an upper-respiratory infection that has progressed to unilateral purulent nasal discharge and discomfort in the right maxillary teeth. The physician performs and documents a detailed history and detailed examination. The physician determines that the medical decision making is of low complexity and also documents this in the patient’s medical record. This new patient encounter is reported with E/M service code 99203 Office or other outpatient visit.

During the examination, the patient communicates to the physician that the hearing in his left ear is not as distinct as his right ear. Upon examination of the left ear, the physician notes a large amount of impacted cerumen. The physician proceeds to suction the impacted cerumen in the patient’s left ear.

To report this patient encounter, the physician appends Modifier ‘-25’ to code 99203, and separately reports code 69210, Removal impacted cerumen (separate procedure), one or both ears to indicate that both a significant E/M service and a procedure were performed on a given day.

Example 3 (May 2011, CPT® Assistant):

A 4-year-old slips on the edge of a pool, strikes the mandible and experienced a 3.5-cm serrated and curvilinear, full-thickness laceration of the chin. The child’s pediatrician elects to widely excise the serrated skin margins and undermine the dermis from the subcutaneous tissue to reduce the tension on the suture line. The wound is then approximated in layers with absorbable interrupted sutures and a running subcuticular closure.

This procedure would be reported with code 13132, Repair complex, forehead, cheeks, chin, mouth neck, axillae, genitalia, hands and/or feet; 2.6 to 7.5 cm. Any significant, separately identifiable evaluation and management (E/M) service performed in addition to the wound repair would be reported separately using modifier 25.

All services and procedures include an “inherent” E/M component. A brief history and physical prior to a same-day scheduled outpatient procedure are included components of the procedure itself. Even if the physician provides an assessment and plan, you probably should not report a separate E/M service unless the patient has a new, unrelated complaint or has experienced a worsening of symptoms that prompts a new history, exam and medical decision-making process that might include additional testing or therapy.

The question persists: How do you decide if an E/M service is truly “significant” and “separately identifiable” (and separately reportable with modifier 25)? Ask yourself, “Can I pick out from the documentation a clear history, exam and medical decision-making process apart from any other procedures the physician performs on the same day?” If so, you’ve probably got a billable service with modifier 25.


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