EM Coding Alert

Here’s what your documentation needs to show.

Now that coders must select encounter and management (E/M) service codes solely on time spent or medical decision making, many folks may be confused about how and when to 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).

In the past, you could make sure providers included sufficient data in the History and Physical Exam sections so any reviewers could easily see the separate E/M service performed, in addition to the procedure.

If you’re struggling to make the distinction obvious, read on for some expert tips for otolaryngology scenarios.

Consider Mirror Exam and Laryngoscopy

Example: An otolaryngologist needs to visualize the larynx of a patient who has a history of laryngeal cancer, so they perform a mirror exam as part of the evaluation and management service for that day. The doctor is unable to fully visualize the larynx, so they perform a laryngoscopy to get a better view of the structures.

Question: In this case, can you report an E/M code with modifier 25 appended to represent the work from the E/M and mirror exam, or should you only report the laryngoscopy?

Solution: “At present with the 2021 guidelines, the only history and physical information that require documentation relating to office-based E/M services are those which are clinically relevant; that is, history and exam play no role in choosing the E/M level,” says Richard Waguespack, MD, clinical professor in the Department of Otolaryngology-Head & Neck Surgery at the University of Alabama at Birmingham. “That is only based on time or medical decision making (MDM), which must be adequately documented.”

“To report an E/M plus a procedure, one must perform, and document, enough to satisfy that level of new or established work in addition to that of the procedure,” Waguespack says.

For instance, if the physician performs a flexible laryngoscopy for routine cancer surveillance but there are no new problems to address, you would typically not be able to justify an E/M service in addition to the laryngoscopy, so you’d only report the code for the scope.

“If a new problem (e.g., worsened swallowing, a neck mass, etc.) is present, there could be sufficient extra E/M work performed and reported in addition to the laryngoscopy,” Waguespack says. “Of course, the medical necessity for endoscopy of the larynx/hypopharynx should be documented in the note whether performed alone or with an E/M service, and it would not hurt to mention that the mirror exam would not allow adequate clinical assessment of the patient.”

Do this: The documentation must still justify a separate E/M service, whether you document the history and physical or not. Therefore, the most important determination you will need to make before billing for a separate E/M with modifier 25 is deciding whether your provider performed any additional work above and beyond the work involved in the procedure. This means knowing what typical pre- and post-work is included in the procedure code, and reading the progress note carefully to evaluate what should be included in the procedure code and what should be billed separately.

“The provider should also remember when doing a diagnostic procedure like a nasal endoscopy, laryngoscopy, or nasopharyngoscopy that they need a procedure note that includes the anesthetic used, the scope used, and the findings from the endoscope, and none of this should be found in the exam section of the E/M service,” says Barbara J. Cobuzzi, MBA, CPC, COC, CPC-P, CPC-I, CENTC, CPCO, CMCS, of CRN Healthcare in Tinton Falls, New Jersey.