Be Careful when Separately Reporting E/M and Minor Surgical Procedures
Consider both Medicare and CPT® guidelines before billing both services using modifier 25.
The issue of whether an evaluation and management (E/M) service is separately reportable from a service classified as a minor surgical procedure is not new. The Centers for Medicare & Medicaid Services (CMS) publishes a variety of reimbursement guidance through Internet-Only Manuals, which are based on the statutory and regulatory provisions of the Social Security Act. Before you separately report E/M services in addition to services that CMS classifies as minor surgical procedures, review the CMS National Correct Coding (NCCI) Policy Manual and CPT® for guidance. Once you resolve the issue of properly coding the service, also address the issue of medical necessity, which is the limiting factor when determining whether separate reporting of the E/M service is appropriate.
Note: This article addresses separate reporting of E/M services with modifier 25 as addressed under CMS reimbursement rules. Because commercial payers can and do have separate policies, this information may or may not be relevant to payers other than Medicare.
For services classified as minor surgical procedures with “000” follow-up days, the CMS global surgical period is applicable where the E/M service is provided on the same date as the minor surgical procedure (Extremity CMT services are classified under the MPFSDB as a “XXX” or non-surgical procedure for which the surgical period rules are inapplicable.). So be sure to review those rules, which are in the NCCI Policy Manual and other CMS publications. Although the NCCI Policy Manual addresses reporting of an E/M within the surgical period, there is no general prohibition of E/M reporting in addition to a minor surgical procedure, as you might think. Chapter 1, Section D of the NCCI Policy Manual describes Medicare global surgery rules with respect to E/M services as (emphasis added):
D. 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 apply to specific sections of CPT®. As indicated in the aforementioned NCCI Policy Manual provision, E/M work not associated with the decision to perform the surgical procedure is separately reportable using 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. For many minor surgical procedures, especially those provided under a plan of care, the decision to perform the procedure has already been made. Instead, documented E/M analysis at each visit, which is often demanded by payers, generally focuses on findings needed to justify the effectiveness of care at the visit in question. Regardless, E/M work not associated with the decision to perform the “surgical” procedure is not the only circumstance where separate reporting is allowed when consistent with analyzing the CPT® definition of modifier 25.
Proper reporting of modifier 25, which is necessary for separate reimbursement, is clarified in the Medicare Claims Processing Manual (IOM Pub 100-4, Chapter 12, section 30.6.6.B) provisions:
B. 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.
This Medicare Claims Processing Manual provision explains that the physician is only required to “indicate” performance of a significant and separately identifiable E/M service. Unfortunately, CMS does not provide guidance as to how a physician or other qualified practitioner would meet this requirement, other than by documenting the E/M work as a means of substantiating the use of modifier 25. This provision also confirms that different diagnoses for the E/M and surgical procedure are not required. There is also an emphasis on the requirement to appropriately document the E/M service, as well the basis for the E/M qualifying as “significant or separately identifiable.”
To resolve the coding issue of when it is appropriate to report modifier 25, we turn to coding guidance in the Medicare Program Integrity Manual (IOM Pub 100-8, Chapter 3, section 126.96.36.199) that says, “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, you must satisfy CPT® Editorial Panel guidance for appropriate use of modifier 25 to report the E/M service using that modifier.
CPT® Editorial Panel Guidance
Although many addressing this issue rely on CPT® Editorial Panel guidance found in the CPT® code book, few objectively apply it. The CPT® Editorial Panel provides in the definition for modifier 25 a precise and unambiguous definition of the term “significant and separately identifiable” (bold, underline 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.
As a result, an E/M service is significant, separately identifiable:
- In circumstances where the documentation satisfies the criteria of history, examination, and decision-making for the E/M level reported; or
- If it substantiates that more than 50 percent of the physician or other qualified practitioner’s face-to-face time with the patient was spent counseling or coordinating care for the level of E/M reported.
This definition parallels the additional guidance by both CPT® and CMS that different diagnoses are NOT required when reporting E/M services separately. Be sure you understand that both CMS and CPT® guidance, which are often cited relative to this issue, consistently conclude that where an E/M is “significant, separately identifiable,” it may be separately reported. For that reason, the CPT® definition is critical to evaluate the propriety of reporting the E/M service. As a purely technical matter, an E/M may always be separately reported where the analysis performed in addition to the procedure shows sufficient history, examination, and decision-making (or counseling/coordination of care time) to support the level of E/M service reported.
Although this is not the result you’d anticipate, or even want, it is the accurate result as purely an issue of proper coding. Because it is considered inappropriate to report a separate E/M in addition to a minor surgical procedure on every visit, there must be a problem with doing so that we can identify.
The aforementioned coding rules do not provide the answer. The answer and the restriction to such reporting is therefore based on whether such E/M analysis is medically necessary. It often is not; however, for procedures performed as part of a course of treatment or for a known and previously diagnosed condition, providers often document their daily history, examination, and decision-making analysis in a Pavlovian fashion because payers demand it. In most cases, such analysis is not necessary once the subjective functional and objective problems are identified and a plan of care has been developed. Because the subjective and objective data does not change in any substantive way, continuously recording such information only leads to repetitive content and complaints of cloning. The true solution is to recognize that after a plan of care for an ordered minor surgical procedure is established, providers should implement that plan and draft treatment notes that support performing the procedure pursuant to that plan — providing the payer with the necessary details of the service to support the code(s) reported.
Progress analysis at periodic points during a course of care, which may be necessary based on changes in the patient’s subjective and objective status (as a result of the services ordered), might warrant performing a significant and separately identifiable E/M service. Such E/M work would focus on changes in the subjective and objective status as a result of either improvement, exacerbation, or an emerging new problem, and the analysis would include changes to the diagnosis and plan of care (decision-making) based on those changes. In this circumstance, the documentation for such an encounter is recognizably different from that for daily treatment encounters, and the documentation (as a whole) is likely to be more focused on the effect of treatment rather than a repetitive recitation of the patient’s complaints and examination findings.
In other circumstances, the E/M might be supported based on the need to evaluate indirectly-related co-morbid conditions. In many cases, co-morbid conditions management is necessary because of the impact those problems have on the condition being treated with a procedure.
Example: Consider the debridement of a wound site in a patient with venous hypertension, hyperlipidemia, morbid obesity, and hypertension. Although E/M analysis of the wound itself generally is included in the reimbursement for the debridement procedure, E/M of the other, indirectly-related conditions would be necessary because control of those conditions will affect how well (or if) the wound heals. This work is easily distinguishable, making it separately necessary and billable with modifier 25, consistent with the CPT® definition of modifier 25.
Justify the Analysis
Ultimately, although CPT® permits separate reporting of an E/M service with modifier 25 in any case where the documentation supports the scoring of an E/M service, such reporting is recommended only where clinical circumstances justify the need for such analysis.
To prevent unnecessary provider documentation, payers need to recognize that repeated history, examination, and decision-making analysis is not needed at every encounter; and they should encourage providers to focus on documenting the procedure performed pursuant to an established plan of care. Progress analysis should be performed in response to substantive and significant changes in the patients subjective and objective status. Be sure documentation focuses on the changes achieved from the care provided, as well as the clinical decision-making those changes should trigger relative to anticipated goals and/or changes to the plan necessary to achieve those goals. Where E/M analysis is needed to examine indirectly related co-morbid conditions, the need for analysis is more easily justified. Assuming appropriate documentation, either case supports separate reporting of the E/M work based on the need to perform the analysis and make decisions based on the documented findings.
$1.85 Million Paid to Settle Urology Modifier 25 Whistleblower Case
Separately billing routine evaluation and management (E/M) services provided on the same day as another medical procedure is typically denied by Medicare. Healthcare providers can sometimes separately bill E/M services if they meet certain criteria and 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 claim. Modifier 25 shows payers, such as Medicare, that a healthcare provider went above and beyond the usual E/M of pre-operative and post-operative care associated with the medical procedure; and that it was significant, separately identifiable service. If this modifier gets misused, a provider unbundles a service and receives extra reimbursement — overpayments of Medicare dollars. According to a whistleblower, this is what Skyline Urology allegedly did between Jan. 1, 2013 and Dec. 31, 2016.
Department of Justice announced on Feb. 25 that Skyline Urology agreed to pay the United States $1.85 million to resolve whistleblower allegations that it violated the False Claims Act by improperly billing Medicare for routine E/M services that were not separately billable from procedures performed on the same day.
As part of the settlement, Skyline Urology also has a three-year integrity agreement with the Office of Inspector General. Although the settlement agreement does not mean Skyline is guilty of the whistleblower’s allegations, it resolves the False Claims Act allegations.
To learn more about this case, read the article “Millions Paid to Settle Urology Modifier 25 Whistleblower Case” at www.aapc.com/blog/46019-millions-paid-to-settle-urology-modifier-25-whistleblower-case/.
More on Modifier 25
To learn about the correct use of modifier 25, go to these other articles on AAPC’s Knowledge Center:
Anthem Rescinds Modifier 25 Payment Reductions:
Modifier 25 for E/M on the Day of an Injection Procedure:
4 “Must Haves” to Append Modifier 25:
NCCI Policy Manual, Chapter 1
Medicare Claims Processing Manual, Chapter 12 – Physicians/Nonphysician Practitioners (Pub 100-4, Chapter 12, § 30.6.6.B): www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/clm104c12.pdf
Medicare Program Integrity Manual, Chapter 3 – Verifying Potential Errors and Taking Corrective Actions (Pub 100-8, Ch. 3, §188.8.131.52): www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/pim83c03.pdf
CPT® Editorial Panel, CPT® code book