Billing an E/M With a Minor Procedure: Yes, You Can!
Consider this otolaryngology case study to decide when to append modifier 25.
The Cigna Group recently postponed a requirement for documentation to be submitted with all claims that include a 25 modified office or other outpatient evaluation and management (E/M) service (CPT® 99212-99215) and a minor procedure. Although the payer didn’t follow through on this requirement, every physician practice that submits these claims needs to make sure their documentation will pass clinical review — especially otolaryngologists billing an E/M with an unplanned diagnostic endoscopy.
Here’s the Situation
Typical minor procedures performed in an outpatient setting are either therapeutic or diagnostic. And diagnostic procedures are usually scheduled (e.g., a colonoscopy by a gastrointestinal specialist, a nerve conduction study by a neurologist, or a cardiac stress test by a cardiologist). But in the specialty of otolaryngology, physicians often perform unplanned diagnostic endoscopies during E/M encounters. Examples include a diagnostic nasal endoscopy for nasal and sinus complaints (31231), a nasopharyngoscopy for eustachian and complaints of the nasopharynx (92511), and laryngoscopy (31575) for complaints in the throat. These endoscopies are diagnostic procedures with zero global days and are performed as unplanned procedures in most cases.
Case in Point
In otolaryngology, the physician will perform a manual inspection of the nose and sinuses, the nasopharynx, and/or the larynx while examining the patient. If the physician cannot adequately examine the patient through visual inspection, or the manual exam does not provide enough information, the physician may decide to perform an unplanned diagnostic endoscopy to better ascertain the condition of the patient’s nose/sinuses, nasopharynx, and/or larynx.
Consider this example: The established patient complains of nasal congestion, headaches, and facial pressure. The doctor completes a history of present illness (HPI), review of systems (ROS), and exam of the patient’s head, face, nose, mouth, neck, and thyroid. The doctor cannot get adequate visualization of the nose and sinuses with a speculum and decides a diagnostic nasal endoscopy is necessary to get a better look at the nasal cavities. The provider completes a full nasal endoscopy procedure note, which includes the anesthetic used, the time waited for the anesthetic to take effect, and the condition of interior nasal cavities, septum, middle meatuses, superior meatuses, turbinates, and sphenoethmoidal recesses on both sides of the nose.
As a result of his findings, the doctor documents an assessment and plan and medical decision making (MDM), which will determine the level of the E/M service. The assessment finds that this patient has chronic pansinusitis and nasal polyps. The doctor also determines that the headaches are in the frontal component. The doctor introduces the patient to an irrigation system and prescribes two types of medicated nasal sprays for the polyps. The doctor discusses the possibility of surgery in the future with the patient if the medication does not work in reducing the polyps. The doctor also discusses the possibility that minor surgery might open the nasal obstructions or, if the congestion and polyps get worse, a more radical surgery may have to be considered. That would be major surgery, but low risk given the patient’s age, the physician documents.
Consider the Work Involved
The Centers for Medicare & Medicaid Services (CMS) publishes the physician pre-service, intra-service, and post-service time that goes into determining the value for each CPT® code (see Resources for a link). These pre- and post-service times for the minor procedure cannot include any time spent on the E/M service and vice versa.
For otolaryngology, a diagnostic nasal endoscopy (31231) has 5 minutes pre-service evaluation time and 3 minutes post-service time. A diagnostic nasopharyngoscopy (92511) has 4 minutes pre-service evaluation time and 3 minutes post-service time. A diagnostic laryngoscopy (31575) has 8 minutes pre-service evaluation time and 5 minutes post-service time. A therapeutic endoscopy involving sinus debridement or polypectomy, unilateral (31237) has 17 minutes pre-service evaluation time and 5 minutes post-service time. This is time related to the minor procedure and not the E/M service.
Although the doctor did not document the time it took to do the pre-service, intra-service, and post-service, more than 15 minutes was spent in addition to the time spent on the E/M. Noting this time may be something to add in the practice’s clinical documentation improvement education.
Performing the unplanned diagnostic endoscopy aided in the physician’s MDM. The note describes a significant and separately identifiable E/M with MDM for a chronic problem that is not stable and prescription drug management, which supports a 99214-25 Office or other outpatient visit for the evaluation and management of an established patient …. The note also describes the anesthetic used and detailed endoscopic findings for all the relevant structures in the nose and sinuses, which supports an unplanned diagnostic procedure (31231 Nasal endoscopy, diagnostic, unilateral or bilateral (separate procedure)).
Although modifier 25 is not defined as “decision to perform” a procedure, a catch-22 exists here. When we have a diagnostic minor procedure, it’s billable with a 25 modified E/M if that minor procedure was not scheduled and the physician decided to perform that procedure during the E/M encounter.
AMA CPT® Assistant March 2023
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