Fight for your right to be paid for properly documented claims.
By G.J. Verhovshek
When commenting on Abraham Morse’s, MD, MBA, article “Same-day E/M and Office Procedure: Yes, You Can!” (March 2012 Coding Edge, pages 16-17), several readers shared that insurers (including Medicare contractors) routinely deny evaluation and management (E/M) claims when reported with other procedures on the same day, and asked how to avoid such denials. The answer is three-fold: Know the applicable guidelines, be ready to submit documentation to backup your claim, and pursue appeals aggressively to get the payment you deserve.
Know the Guidelines
Under both the Centers for Medicare & Medicaid Services (CMS) and CPT® guidelines, an 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.”
Document to Support Your Claim
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 (MDM) 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 MDM apart from any other procedures the physician performs on the same day?” If so, you’ve probably got a billable service with modifier 25.
MYTH BUSTER: Coding legend has it that an E/M service must reach at least a “level-III” service (e.g., 99203 Office or other outpatient visit for the evaluation and management of a new patient, which requires these 3 key components: A detailed history; A detailed examination; Medical decision making of low complexity for a new office patient, or 99213 Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: An expanded problem focused history; An expanded problem focused examination; Medical decision making of low complexity for an established office patient) to qualify as “significant,” as defined by modifier 25. However, this requirement appears nowhere in CMS guidelines; and according to CPT® Assistant (September 1988), modifier 25 “is not restricted to a particular level of service.”
To support your claims further, when an E/M service leads to an unplanned, same-day procedure, be sure that documentation clearly shows the decision to perform the procedure was made during the encounter.
Per CMS transmittal R954CP, you do not need to submit full documentation with your claim, but the documentation must be available upon request (this will be important for our next step).
Several readers have had an experience similar to that of an AAPC member who told us, “I just got off the phone with [her state] Medicare, and they say their system is set to flag E/M codes billed with procedures done on [the] same day. Claims may be denied if the codes are billed with [the] same diagnosis. The only way to get payment is to appeal.” Another reader commented that her insurer never allows separate billing for a same-day E/M and procedure.
If your Medicare payer routinely denies modifier 25 claims, drop a little knowledge on them: Per national CMS policy, Medicare contractors may impose prepayment requirements on modifier 25 claims only if the payer has specific evidence of misuse or abuse. This instruction is detailed in the Medicare Claims Processing Manual, publication 100-04, chapter 12, section 30.6.6.B:
“When a carrier has conducted a specific medical review process and determined, after reviewing the data, that an individual or a group has high use of modifier ‘-25’ compared to other physicians, has done a case-by-case review of the records to verify that the use of modifier was inappropriate, and has educated the individual or group, the carrier may impose prepayment screens or documentation requirements for that provider or group.”
In every case, if you’ve received a denial for a clean claim supported by documentation, be sure to appeal. Yes, appeals mean extra work, but the coding guidelines are clearly stated and on your side, and consistently writing off these claims can have a calamitous effect on the practice’s bottom line.
Tip: For more information on how to pursue appeals, see “Appeal Claims Strategically to Capture Revenue You Deserve” on page 42 in this issue of Coding Edge.
Beware of Modifier 25 Exceptions
There are three specific circumstances under which the normal requirements for billing a separate E/M service with a same-day minor procedure do not apply, per the Medicare Claims Processing Manual, publication 100-04, chapter 12, section 30.6.6.B:
“When inpatient dialysis services are billed (CPT® codes 90935, 90945, 90947, and 93937), the physician must document that the service was unrelated to the dialysis and could not be performed during the dialysis procedure.
When preoperative critical care codes are being billed on the date of the procedure, the diagnosis must support that the service is unrelated to the performance of the procedure.
Carriers may not permit the use of modifier 25 to generate payment for multiple evaluation and management services on the same day by the same physician, notwithstanding the CPT® definition of the modifier.”
G.J. Verhovshek, MA, CPC, is managing editor at AAPC.
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