Do I Use 25 or 59 for Same-day Assessment and E/M?

Do I Use 25 or 59 for Same-day Assessment and E/M?

Have a Coding Quandary? Ask John

 

Q: Can you advise on the appropriate modifier usage for billing an emergency department evaluation and management (E/M), such as 99284, with G0396 to avoid bundling edits? Should the physician apply modifier 25 on the E/M? Should she apply 59 on G0396? Or should she both apply 25 to the E/M and 59 to G0396?

A: 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 appropriate E/M service code when the provider performs “a significant, separately identifiable E/M above and beyond the other service provided, or beyond the usual preoperative and postoperative care associated with the procedure that was performed” (CPT® Appendix A: Modifiers).

Evaluation and Management – CEMC

By contrast, modifier 59 Distinct procedural service “is used to identify procedure/services other than E/M services, that are not normally reported together, but are appropriate under
the circumstances.”

In this case, the only (non-E/M) service provided is the alcohol/substance abuse assessment; therefore, modifier 59 is not appropriate. To report the significant, separately identifiable E/M service on the same day as the assessment, proper coding is G0396 Alcohol and/or substance (other than tobacco) abuse structured assessment (e.g., audit, dast), and brief intervention 15 to 30 minutes and 99284-25 Emergency department visit for the evaluation and management of a patient, which requires these 3 key components: A detailed history; A detailed examination; and Medical decision making of moderate complexity.

Although not required, it’s helpful to document the E/M service separately in the note. This helps to illustrate the separate nature of the E/M. The E/M and other procedure or service may be related (i.e., the reason for the E/M also may be the reason for the other procedure or service), but the work of the E/M service must meet all requirements of the chosen level of service.

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John Verhovshek

John Verhovshek

John Verhovshek, MA, CPC, is Managing Editor at AAPC. He has covered medical coding and billing, healthcare policy, and the business of medicine since 1999. He is an alumnus of York College of Pennsylvania and Clemson University, and a member of the Asheville-Hendersonville AAPC Local Chapter.
John Verhovshek

About Has 402 Posts

John Verhovshek, MA, CPC, is Managing Editor at AAPC. He has covered medical coding and billing, healthcare policy, and the business of medicine since 1999. He is an alumnus of York College of Pennsylvania and Clemson University, and a member of the Asheville-Hendersonville AAPC Local Chapter.

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