EM Coding Alert

Documentation is the key to claims with separate E/Ms.

Coders that hope to report E/M services correctly when the provider performs multiple services during the same encounter need to know modifier 25 in and out.

Why? Failure to use 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), when necessary, can result in denials or delays in payments. Check out this advice aimed at helping you get modifier 25 claims right the first time.

Remember: 25 for E/Ms Only

In basic terms, modifier 25 is used only on an E/M service that is “separate and significant from another procedure or service at the same encounter,” explains Melanie Witt, RN, CPC, MA, an independent coding expert based out of Guadalupita, N.M. This does not mean that a different diagnosis is required, but the note must clearly indicate that the E/M dealt with issues that were not part of the other services even though it may have been for the same condition. The visit must be separately identifiable from the procedure, such that it is clear that the two services were medically necessary at the time they were both rendered.

Witt shares this example: A new patient presents with complaints of severe vaginal bleeding. The physician takes the patient’s history, evaluates her for contributing factors, and performs an examination. Then, the physician discusses treatment options with the patient, and recommends an endometrial biopsy. The patient requests that the provider perform the procedure that day, because she lives 50 miles from the practice.

After the E/M service, the physician performs an endometrial biopsy. Notes indicate a level-four E/M service.

On the claim, you would report:

• 58100 (Endometrial sampling [biopsy] with or without endocervical sampling [biopsy], without cervical dilation, any method [separate procedure] ) for the biopsy.
• 99204 (Office or other outpatient visit for the evaluation and management of a new patient, which requires these 3 key components: a comprehensive history; a comprehensive examination; medical decision making of moderate complexity) for the
  
• E/M service
• Modifier 25 appended to 99204 to show that the biopsy and the E/M were separate services.
• N93.9 (Abnormal uterine and vaginal bleeding, unspecified) appended to 51800 and 99204 to represent the patient’s condition.

Check Off These Elements on E/M-25 Claims

On modifier 25 claims, “the physician must show, by documentation in the medical record, that on the day he performed the procedure, the patient’s condition required a separately identifiable E/M service above and beyond the usual care associated with the procedure that was performed,” says Mary I. Falbo, MBA, CPC, CEO of Millennium Healthcare in Lansdale, Pa.

So you’ll have to be sure that there is evidence of a separate E/M on your encounter forms before using modifier 25.

The key is recognizing when your provider’s extra work is “significant” and, therefore, additionally codeable, says Falbo. CPT^® does not define “significant,” unfortunately, but Falbo recommends asking yourself the following questions when deciding whether to report an E/M-25 along with another service:

• Did the provider perform and document the key components of a problem-oriented E/M service for the complaint or problem?
• Could the complaint or problem stand alone as a codeable service?
• Is there a different diagnosis for this portion of the visit?
• If the diagnosis will be the same, did you perform extra physician work that went above and beyond the typical pre- or postoperative work associated with the procedure code?

If you can answer “yes” to any of these questions, you might be able to report an E/M with modifier 25. However, if the visit was only to assess if the patient needed the procedure, the visit would not be separately identifiable, and thus not codeable.