Understand the Complexity of Reporting Same Day CMT and E/M Services
In the absence of payer guidance, look to CMS and CPT® for guidance on reporting an E/M as a separate service from chiropractic manipulative treatment with modifier 25.
Editor’s Note: Healthcare Business Monthly was recently asked about reporting evaluation and management (E/M) services separately from chiropractic manipulative treatment (CMT) of the spine. As with most situations regarding 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 the answer is complex and potentially contentious, and deserves special explanation. The references cited in this article may not be relevant, depending on the payer at issue. Beyond Medicare, check individual payer medical policies for guidance.
The issue of whether an E/M service is separately reported from a minor surgical procedure, generally, or CMT of the spine, specifically, is not new. Payers other than Medicare often offer little guidance. In such a circumstance, the National Correct Coding Initiative (NCCI) Policy Manual is a reasonable starting point for determining when it is appropriate to separately report an E/M service and a CMT (or other minor surgical procedure) on the same day.
CMS Guidance on Proper Use of Modifier 25
Under the Medicare Physician Fee Schedule (MPFS), spinal CMT services (CPT® 98940-98942) are classified as minor surgical procedures with “000” follow-up days. Therefore, the CMS global surgical period concept is relevant to resolving this issue.* Fundamentally, while the NCCI Policy Manual addresses the reporting of an E/M within the surgical period, there is no general prohibition to E/M reporting in addition to a minor surgical procedure, as many would conclude.
*Extremity CMT services are classified under the MPFS Database as a “XXX” or non-surgical procedure, for which the surgical period rules are inapplicable.
Chapter 1, Section D of the NCCI Policy Manual describes Medicare Global Surgery Rules with respect to E/M services as (emphasis added):
Evaluation and Management (E&M) Services
Medicare Global Surgery Rules define the rules for reporting evaluation and management (E&M) services with procedures covered by these rules. This section summarizes some of the rules.
All procedures on the Medicare Physician Fee Schedule are assigned a Global period of 000, 010, 090, XXX, YYY, or ZZZ. The global concept does not apply to XXX procedures. The global period for YYY procedures is defined by the Carrier. All procedures with a global period of ZZZ are related to another procedure, and the applicable global period for the ZZZ code is determined by the related procedure.
If a procedure has a global period of 000 or 010 days, it is defined as a minor surgical procedure. In general 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 fact that the patient is “new” to the provider is not sufficient alone to justify reporting an E&M service on the same date of service as a minor surgical procedure. NCCI contains many, but not all, possible edits based on these principles.
These rules are replicated in the subsequent chapters of the NCCI Policy Manual, which are applicable to specific sections of CPT®. As indicated in the aforementioned provision of the NCCI Policy Manual, E/M work unassociated with the decision to perform the surgical procedure is separately reported using modifier 25.
For chiropractic services provided under a plan of care, the decision to perform manipulation has already been made; therefore, documented subjective (history) and objective (exam) findings at each visit – which are often demanded by payers – in most cases have little to do with the decision to perform manipulation. Instead, this work is performed to (hopefully) substantiate changes in the patient’s subjective and objective status as a result of previously provided care. The basis for this documentation requirement is to demonstrate that the course of treatment provided is medically necessary. Because you can argue that such analysis has nothing to do with the decision to perform the surgical procedure, you might conclude that this E/M work is separately reported under the NCCI rule. Regardless, this is not the only circumstance where separate reporting is permissible, consistent with the CPT® definition of modifier 25. This is addressed in the Medicare Claims Processing Manual, Pub. 100-4, Chapter 12, Section 30.6.6 (emphasis added):
CPT Modifier “-25” – Significant Evaluation and Management Service by Same Physician on Date of Global Procedure
Medicare requires that Current Procedural Terminology (CPT) modifier -25 should only be used on claims for evaluation and management (E/M) services, and only when these services are provided by the same physician (or same qualified nonphysician practitioner) to the same patient on the same day as another procedure or other service. Carriers pay for an E/M service provided on the day of a procedure with a global fee period if the physician indicates that the service is for a significant, separately identifiable E/M service that is above and beyond the usual pre- and post-operative work of the procedure. Different diagnoses are not required for reporting the E/M service on the same date as the procedure or other service. Modifier -25 is added to the E/M code on the claim.
Both the medically necessary E/M service and the procedure must be appropriately and sufficiently documented by the physician or qualified nonphysician practitioner in the patient’s medical record to support the claim for these services, even though the documentation is not required to be submitted with the claim.
As stated in the manual, the physician is only required to “indicate” performance of a significant and separately identifiable E/M service. Unfortunately, CMS does not provide guidance on how a physician or other qualified practitioner meets this requirement other than by documenting the E/M work to substantiate the use of modifier 25.
The manual confirms that different diagnoses for the E/M and the minor surgical procedure are not required. It also emphasizes that appropriate documentation is required for the E/M work, as well as the need to perform that work.
To resolve the issue of when it is appropriate to report modifier 25, which is ultimately a coding issue, turn to guidance in the Medicare Program Integrity Manual, Pub. 100-8, Chapter 3, Section 220.127.116.11, pertaining to proper coding:
The MACs, CERT, Recovery Auditors, and ZPICs shall determine that an item/service is correctly coded when it meets all the coding guidelines listed in the Current Procedural Terminology-4 (CPT-4), Coding Clinic for ICD-9, Coding Clinic for HCPCS, and any coding requirements listed in CMS manuals or MAC articles.
Based on this instruction, as long as the documentation demonstrates compliance with CPT® Editorial Panel guidance, separate reporting of the E/M service with modifier 25 is appropriate.
CPT® Editorial Panel Guidance
The CPT® Editorial Panel provides in the CPT® code book a precise and clear definition of the term “significant, separately identifiable:” (emphasis added)
Description: 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:
Definition: It may be necessary to indicate that on the day a procedure or service identified by a CPT code was performed, the patient’s condition required a significant, separately identifiable E/M service above and beyond the other service provided or beyond the usual preoperative and postoperative care associated with the procedure that was performed. A significant, separately identifiable E/M service is defined or substantiated by documentation that satisfies the relevant criteria for the respective E/M service to be reported (see Evaluation and Management Services Guidelines for instructions on determining level of E/M service). 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. This circumstance may be reported by adding modifier 25 to the appropriate level of E/M service. Note: This modifier is not used to report an E/M service that resulted in a decision to perform surgery. See modifier 57. For significant, separately identifiable non-E/M services, see modifier 59.
An E/M service is, by definition, significant and separately identifiable and therefore separately reported with modifier 25 in circumstances where the documentation satisfies the following criteria:
Documentation supports sufficient history, examination and/or medical decision-making (MDM) for the E/M level reported; or
Substantiates that more than 50 percent of the physician or other qualified practitioner’s face-to-face time with the patient was spent in the performance of counseling or coordination of care for the level of E/M reported.
This definition is consistent with the additional guidance from both CPT® and CMS that different diagnoses are NOT required when reporting E/M services separately.
CMS and CPT® guidance consistently conclude an E/M service that is “significant, separately identifiable,” is separately reported — provided there is documentation of sufficient history, examination, and MDM (or counseling/coordination of care time) to support the level of E/M service reported.
Putting It All Together
Although this is not the result most anticipate or even want, it is the accurate result as an issue of proper coding. Because it would be irrational to report a separate E/M service in addition to a CMT on every visit, there must be an identifiable problem with doing so. The coding rules addressed above do not provide the answer. Returning to the NCCI guidance, the answer and the potential restriction to such reporting is based on whether such E/M analysis is medically necessary. It often is not; however, chiropractors provide documentation of their daily SOAP (subjective, objective, assessment, and plan) analysis routinely simply because payers demand it. In chiropractic, like physical therapy, such analysis is not really necessary once the subjective functional and objective problems have been identified and a plan of care developed. Because the subjective and objective data does not change daily, continuous recordation of such information only leads to repetitive content and complaints of cloning.
Solution: Recognize that, after a plan of care is established, chiropractors should implement that plan and draft treatment (as opposed to SOAP) notes that support performance of the treatment performed pursuant to that plan – providing the necessary details of the service, such as location, contact, and time, to support the codes and/or units of service reported.
Progress analysis, which would be based on performance of a significant and separately identifiable E/M service, would focus on changes in the subjective and objective status as a result of either improvement, exacerbation, or the emergence of a new problem. Such analysis should include any changes to the diagnosis and plan of care based on the identified changes to the patient’s subjective and/or objective status. Under this approach, not only would the documentation for such encounter be recognizably different from that for daily treatment encounters, the documentation (as a whole) would likely be more focused on the effect of treatment rather than a repetitive recitation of the patient’s complaints and examination findings.
Ultimately, while CPT® certainly permits separate reporting of an E/M service with modifier 25 in any case where the documentation of history, examination, and MDM (or counseling/coordination of care time) support the scoring of an E/M service, such reporting is recommended only where the clinical circumstances warrant such analysis. To preclude unnecessary E/M work, payers need to recognize that SOAP analysis is not needed at every encounter and should encourage providers to focus on documenting the treatment performed during routine treatment visits. Periodic progress evaluations (performed in response to substantive and significant changes in the patient’s subjective and objective status) should focus on the changes in the patient’s subjective and objective status as well as the clinical decisions made in response to those changes relative to the diagnosis, anticipated goals, and/or changes to the plan necessary to achieve those goals. These encounters, with proper documentation, justify separate reporting of the E/M work based on the need to perform the analysis and document the findings and decisions made based on those findings.
Frequency for such analysis is not easily predicted. Because the response of each patient cannot be predicted and varies, there is no standard time frame for when such analysis might be necessary. For this reason, policies by either providers or payers suggesting that such analysis is appropriate once every 30 days or every 12 visits are neither rational nor justifiable. Progress analysis should be performed when necessary based on the subjective and objective status of the patient. Because patients do not respond or improve on a predictable or linear basis, and because necessity is ultimately the issue that restrains the ability to separately report an E/M in addition to a minor surgical procedure, such as CMT of the spine, the frequency of when such analysis should be performed and necessary depends on whether there was evidence of a change in the patient’s clinical status to warrant the E/M work reported or where there was a lack of change requiring a revision to, or termination of, the plan of care.
CMS, NCCI Edits: www.cms.gov/Medicare/Coding/NationalCorrectCodInitEd/index.html
CMS, NCCI Policy Manual Archive: www.cms.gov/Medicare/Coding/NationalCorrectCodInitEd/NCCI-Manual-Archive.html
Medicare Claims Processing Manual, (IOM) Pub 100-04, Chapter 12, § 30.6.6.B
Medicare Program Integrity Manual (IOM) Pub. 100-8, Ch. 3, §18.104.22.168
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