Reporting an E/M Service on the Same Day as a Procedure
Following payer guidelines, using modifiers properly, and checking global packages are key to payment.
By Faith C.M. McNicholas, RHIT, CPC, CPCD, PCS, CDC
Over the past few years, payers have increased claims scrutiny to ensure reimbursement matches the services documented in the patient record. As a result, many healthcare providers either have had a claim denied or have received a request for medical records review when an evaluation and management (E/M) service is performed on the same date of service (DOS) as a procedure.
The Centers for Medicare & Medicaid Services (CMS) enhanced language in the Integumentary section of the National Correct Coding Initiative Policy Manual, version 19.3, which has affected the reporting of an E/M service on the same DOS as a procedure. The new the National Correct Coding Initiative (NCCI) narrative [text emphasized in the original] states:
If a procedure has a global period of 000 or 010 days, it is defined as a minor surgical procedure. E&M services on the
same date of service as the minor surgical procedure are included in the payment for the procedure. The decision to perform a minor surgical procedure is included in the payment for the minor surgical procedure and should not be reported separately as an E/M service.
However, a significant and separately identifiable E&M service unrelated to the decision to perform the minor surgical procedure is separately reportable with modifier 25. The E&M service and minor surgical procedure do not require different diagnoses. If a minor surgical procedure is performed on a new patient, the same rules for reporting E&M services apply.
The statement above indicates an E/M service is included in the minor procedure, but does not preclude you from reporting a separate, significant E/M service, when performed and accurately documented.
Some Medicare carriers may rely on edits not included in the NCCI. For example, the use of 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 varies among CMS carriers; some prefer providers to include modifier 25 when reporting a new patient E/M service with a procedure, while others don’t (e.g., Noridian Administrative Services). Healthcare providers and coders are encouraged to clarify modifier 25 preferences with their regional Medicare and commercial carriers.
Global Surgical Package
For successful, stress-free reporting of E/M services and procedures on the same DOS, you must understand the global surgical package. The CMS Internet Only Manual (IOM) (Claims Processing Manual, publication 100-04, chapter 12, section 40.1) defines all procedures with a global surgery indicator of 0 or 10 as minor surgical procedures.
According to NCCI, modifier 25 may be appended to an E/M code when reported with minor surgical procedures or procedures not covered by global surgery rules to indicate the E/M service is separate and significantly identifiable from other services reported on the same DOS. Because all procedures include pre-, intra-, and post-procedural work that is a required part of the procedure, do not report an E/M code for this work. Payers will consider this to be “procedure code unbundling.”
For example, the work descriptor for CPT® 11100 Biopsy of skin, subcutaneous tissue and/or mucous membrane (including simple closure), unless otherwise listed; single lesion includes:
Pre-operative Work: Prior to biopsy of lesion, obtain pertinent history from patient to include: previous skin cancer, prior treatment history, sun protection history, etc. Discussion with patient will include: indication for biopsy procedure, risks, and benefits; description of biopsy procedure method, and expected result and/or scarring. In addition, patient agreement/informed consent is obtained and staff is advised for preparation of patient and necessary anesthetic, supplies, and instrument tray preparation.
Intra-service Work: Inspection and palpation of the lesion to assess depth and to select most representative site to obtain specimen. Cleanse biopsy site with suitable antiseptic; inject appropriate local anesthetic; apply sterile drapes; obtain skin specimen with scalpel, skin punch, or suitable instrument depending on depth and amount of tissue needed. Collect specimen in labeled formalin container. Undermine wound edges as needed to facilitate repair. Suture to approximate wound edges, or achieve hemostasis with pressure, chemical, or electrocautery, or application of topical hemostatic agents. Apply antibiotic ointment and sterile dressing.
Post-operative Work: Instruction of patient and/or family on postoperative wound care, dressing changes, and follow-up. Patient advised how to recognize significant complications, eg, bleeding, or allergic reaction to antibiotic ointment or adhesive dressings. Patient advised when results will be available and how they will be communicated; completion of medical record; and communication of results to referring physician as appropriate.
A procedure with a global period of 90 days is defined as a major surgical procedure. An E/M service performed on the same day as a major surgical procedure for the purpose of deciding whether to perform the surgical procedure is separately reportable with modifier 57 Decision for surgery. Other preoperative E/M services on the same DOS as a major surgical procedure are included in the global payment for the procedure and are not separately reportable. NCCI does not contain edits based on this rule because Medicare contractors have separate edits; check with your local Medicare administrative contractor or commercial carrier for clarification.
For major and minor surgical procedures, postoperative period E/M services related to recovery from the surgical procedure are included in the global surgical package, as are E/M services related to complications of the surgery that do not require additional trips to the operating room.
Procedure Global Days
Procedure Global Days
|92 days||Day prior to the procedure plus 90 days following the procedure||11 days||Day of the procedure plus 10 days following the procedure|
Postoperative visits unrelated to the diagnosis for which the surgical procedure was performed, unless related to a complication of surgery, may be reported separately on the same day as a surgical procedure with modifier 24 Unrelated evaluation and management service by the same physician or other qualified health care professional during a postoperative period.
NCCI guidelines state:
… for major and minor surgical procedures, postoperative E&M services related to recovery from the surgical procedure during the postoperative period are included in the global surgical package as are E&M services related to complications of the surgery that do not require additional trips to the operating room. Postoperative visits unrelated to the diagnosis for which the surgical procedure was performed unless related to a complication of surgery may be reported separately on the same day as a surgical procedure with modifier 24 (“Unrelated Evaluation and Management Service by the Same Physician or Other Qualified Health Care Professional During a Postoperative Period”).
Examples of Proper Modifier 25 Application
Below are a few examples of appropriate and inappropriate use of modifier 25:
Scenario: A patient presents for the first time with a lesion on the back that won’t heal. The doctor performs a biopsy after a problem-focused history and exam with straightforward medical decision-making.
Coding solution: According to the American Medical Association (AMA) Resource-based Relative Value Scale (RBRVS) Data Manager, CPT® 11100 includes effort to obtain pertinent history, and performing a limited/straightforward exam. NCCI further states, “The fact the patient is ‘new’ to the provider is not sufficient alone to justify reporting an E/M service on the same DOS as a minor surgical procedure, nor is the decision to perform surgery — unless this was a major procedure (90 day global period)”
In this case, an E/M service cannot be justified as distinct, significant, and separately identifiable from the procedure. Report only 11100.
Scenario: A patient presents for followup of a clinically premalignant lesion or nodule of the face previously treated with Efudex with exacerbation. The patient also requires a refill of a topical steroid to treat lichen planus.
The premalignant lesion was previously addressed with no improvement. The provider reviews the medical history form completed by the patient and vital signs are obtained by clinical staff. She obtains an expanded problem-focused history and examination and formulates and develops a treatment plan for the lichen planus. She discusses diagnosis and treatment options with the patient. A decision is made to treat the lesion with LN2. The provider reconciles medication(s) and writes prescription(s). She completes the medical record documentation. She provides necessary care coordination, telephonic or electronic communication assistance, and other necessary management related to this office visit. She handles (with the help of clinical staff) any treatment failures or adverse reactions to medications that may occur after the visit.
Coding solution: Due to the significant, separately identifiable nature of the E/M service provided, as well as the supporting documentation, it is appropriate to report an E/M service at the same time as the procedure.
Scenario: A patient presents for the first time with a clinically benign lesion or nodule of the lower leg that has been present for many years. The provider reviews the medical history form completed by the patient, and vital signs are obtained by clinical staff. She obtains a problem-focused history and examination, formulates a diagnosis, and develops a treatment plan (diagnostic skin biopsy). Biopsy is performed. The provider completes the medical record documentation, provides necessary care coordination, telephonic or electronic communication assistance, and other necessary management related to this office visit, and receives and responds to any interval testing results or correspondence.
Coding solution: All the services described are a standard part of the biopsy procedure. Reporting a separate E/M service is not appropriate.
Faith C.M. McNicholas, RHIT, CPC, CPCD, PCS, CDC, specializes in dermatology coding. A national speaker on coding and regulatory issues, she presents at American Academy of Dermatology annual and summer meetings, AAPC regional conferences, and several other venues. McNicholas has a wide range of experience in various medical specialties, both solo and group practice settings ranging from cardiology to endocrinology to dermatology. Other qualifications include certification in medical billing and coding, and management of medical office and healthcare practice with a degree in Health Information and Management Technology. McNicholas is a certified and approved ICD-10-CM/PCS Expert and Trainer. She is a member of the AAPC Chapter Association, and has served office for the Des Plaines, Illinois, local chapter.