EM Coding Alert

Back to Basics:

Don’t Rely on a New Condition for an Established Patient to Bill E/M

Published on Wed Aug 24, 2022

Hint: Lean heavily on ‘evaluation’ for justification.

Last month, we discussed examples of when two distinct problems can and can’t justify 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). We also started discussing the documentation required to report an E/M service when a new patient comes in for a procedure.

In part two, we’re picking it up with similar examples and advice pertaining to established patient encounters, as well as some specific advice about documentation you can take back to your practice.

New Conditions Require Documentation, Too

You may have heard this common myth: If it’s an existing patient with a new problem, it’s an automatic E/M service. Remember that nothing is automatic without documentation to back it up.

Example: Established patient comes in for a routine immunization. Vaccines were prepared, location sterilized, X-number of cc’s were administered. Prescription written for anti-inflammatory and physical therapy for hip pain.

Some providers think the notes above warrant billing an E/M service along with the immunizations. “Just writing the prescription or finding a different diagnosis doesn’t get us to significant and separately identifiable E/M. We need a robust paragraph of evaluation and management,” said Jeffrey Lehrman, DPM, FASPS, MAPWCA, CPC, CPMA, principal, Lehrman Consulting LLC, Fort Collins, Colorado, during his HEALTHCON presentation, “What Exactly Is a Significant and Separately Identifiable E/M?”

Better option: Let’s say the note had instead said something like this: During routine visit, patient complained of hip pain. After the immunizations, there was discussion that included duration of the pain, possible causes, family history of arthritis. I checked range of motion and degree of pain. The advantages and disadvantages of physical therapy and anti-inflammatory medications were discussed, and a prescription was written for both. X-rays ordered. Orthopedist referred for further evaluation.

The difference between the two sets of notes is clear. The patient came in for their preventive procedure and had a chief complaint of hip pain, which required a completely separate E/M. The work for each didn’t overlap, and the documentation clearly showed that there was both evaluation and management.

Don’t See Separate Dx Codes as a Go-To

Sometimes, there are instances of significant and separately identifiable E/M services that don’t carry an additional diagnosis. “A separate diagnosis code is not necessary for the use of an E/M code with modifier 25,” confirms Chelle Johnson, CPMA, CPC, CPCO, CPPM, CEMC, AAPC Fellow, billing/credentialing/auditing/coding coordinator at County of Stanislaus Health Services Agency in Modesto, California.

Example: Patient presents to the clinic for possible stitches from bumping their head. During the encounter, the patient mentions sudden dizziness and feeling sick to the stomach. The physician checks for additional head trauma that is significant and separate from what is needed to determine how deep the cut is for the sake of closing the wound. The physician discusses and assesses the symptoms, but the ultimate determination was that the patient has no serious injury. The PCP recommends the patient take the rest of the day off from work, get plenty of rest, and try breathing exercises if symptoms persist.

“The evaluation goes beyond what would be needed for standard sutures,” explains Johnson. “But the ultimate determination was that the patient was anxious about receiving stitches,” she says. There is no additional diagnosis code to report, but if the PCP clearly documents that there was a significant and separate E/M, that service is billable in addition to the wound repair.

Look for These Elements in the Patient Record

“Modifier 25 can be tricky to get used to determining,” says Johnson. Remember that the documentation must fully describe the additional E/M service. “If the documentation just supports the procedure, the use of an additional E/M with modifier 25 would not be appropriate,” she says. If you suspect the practitioner’s work warrants use of the modifier, but their documentation does not support modifier 25, it’s important to communicate that to them directly so they fully understand what to document.

Documentation example: For an E/M service that is significant and separately identifiable from a procedure, an auditor is going to want to see that clearly in the notes. “If you’re a provider or you’re looking for something to communicate with your provider, I suggest a paragraph to physically separate the two services,” explained Lehrman. “This is my suggestion as an auditor. Begin the paragraph with something like this: ‘patient has a separate complaint today…,’ then after documenting the evaluation and management of that complaint, the last sentence should be, ‘This evaluation and management of the [condition] was significant and separately identifiable from the procedure of [service],’” he says.