Coding Corner: Decision for treatment calls for separate E/M reporting

November 01, 2015
Area(s) of Interest: Practice Management 

CPR’s “Coding Corner” focuses on coding, compliance and documentation issues relating specifically to physician billing. This month’s tip comes from G. John Verhovshek, the managing editor for AAPC, a training and credentialing association for the business side of health care.   

CPT® and the Centers for Medicare and Medicaid Services (CMS) guidelines state that all procedures (even the most basic) should include an inherent evaluation and management (E/M) component. 

For example, a patient is scheduled to receive a simple injection in the office. A provider meets with the patient to asses her or his fitness to receive the injection, discuss risks and benefits of the injection, and answer basic questions. This work is “bundled,” or included as part of the global service fee for the injection administration, and may not be billed separately. The same rules apply, for instance, when an operating surgeon assesses a patient prior to surgery; the pre-operative assessment is included in payment for the surgical procedure.

What you may report separately, however, is the E/M service during which the physician determines that further treatment is medically necessary.

For instance, the provider records a relevant history and exam, and considers treatment options for a patient with knee pain and swelling. This is a billable E/M service, which may be reported in addition to any medically necessary procedures at the same visit (e.g., x-ray, aspiration to reduce swelling, injection for pain relief). The E/M service is not incidental in this case, but is essential to determine the need for the diagnostic or therapeutic care that follows.

To bill successfully in these circumstances requires both adequate documentation and proper modifier application when submitting the claim.

Ideally, providers should separate their E/M service documentation from that of any other procedure(s) or service(s). For example, the provider could document the history, exam and medical decision-making in the patient’s chart, and record the procedure notes on a different sheet attached to the chart or in a different section within the electronic health record. This demonstrates to the payor and coding staff the distinct nature of the E/M service.

CMS classifies non-E/M procedures as either “major” or “minor.” This information is crucial to determine when you should append a modifier to an E/M service and, if so, which modifier is correct.

In simple terms, major procedures are those with a 90-day global period. All other procedures (e.g., those with a zero-day, 10-day, or other assigned global period) are minor procedures. You can find a global period look-up tool on the CMS website here.

If the provider furnishes a minor procedure and a separate E/M on the same date of service (at the same or a separate encounter), you must append modifier 25 Significant, separately identifiable evaluation and management service by the same physician or other qualified health care professional on the same day of the procedure or other service to the E/M service code.

CPT Assistant (May 2011) provides an example:

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 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.

Choose modifier 57 Decision for surgery—rather than modifier 25—to report a separately identifiable E/M service that occurs on either the same day or the day before, a major surgical procedure, and that results in the decision to perform the surgery, according to the Medicare Claims Processing Manual, section 40.2.

For example, a patient arrives at the emergency department with acute appendicitis, and is taken to surgery. The surgeon performing the surgery may report an E/M service code for the evaluation and history and physical (H&P). Append modifier 57 to the E/M service code to indicate that the E/M is not included in the surgical package.

Remember: If the provider sees the patient for a previously scheduled procedure or service, you would not normally report a separate, same-day E/M service. “Visits by the same physician on the same day as a minor surgery or endoscopy are included in the payment for the procedure, unless a significant, separately identifiable service is also performed,” confirms the Medicare Claims Processing Manual (Chapter 12, Section 40.1).

Text added to the CPT® codebook surgery guidelines in 2015 confirm that “Evaluation and management services subsequent to the decision for surgery on the day before and/or day of surgery (including history and physical)” are “included in addition to the operation per se.”

For example, a patient is seen on Feb. 1 and scheduled for surgery on Feb. 15. The surgeon sees the patient again for an H&P on the day of the surgery. Although you may report the Feb. 1 visit (with no modifier attached, as it occurs well in advance of the surgery and therefore is not included in the surgical package), you would not separately report the H&P on Feb. 15 because the decision for surgery was not made at that visit. Rather, the Feb. 15 visit is bundled into the surgical package. 


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