EM Coding Alert

Hint: Modifier 25 still applies.

Knowing when, or even if, you can code an office/outpatient E/M with a minor procedure has always presented challenges across the specialties, especially in orthopedics.

You know it’s not as easy as simply appending 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 an E/M that occurs in conjunction with a minor surgery, although you will still have to do that in 2021 when the appropriate circumstances apply.

So, has anything changed with modifier 25 use now that the guidelines for the codes have changed? We asked that question to coding expert Lori A. Cox, MBA, CPC, CPMA, CPC-I, CEMC, CGSC, CHONC, and here’s what she had to say.

Straightforward MDM Marks 99202, 99212

The driver in the E/M changes is how you’ll decide between E/M levels: total encounter time or medical decision making (MDM) are the only criteria by which to choose an E/M code now — and you need to pick one or the other. So, you need to make sure you’re lining up your potential separate E/Ms with time or MDM, not the “three key components” of previous years’ E/M coding options (history, examination, MDM). This could be trickier than you think, as Cox illuminated during her recent presentation at HEALTHCON 2020 Regional Virtual Conference: “E/M Guidelines 2021 — Office Visits With Minor Procedures.”

For example, in order to achieve the straightforward MDM level required for 99212 (Office or other outpatient visit for the evaluation and management of an established patient, which requires a medically appropriate history and/or examination and straightforward medical decision making. When using time for code selection, 10-19 minutes of total time is spent on the date of the encounter.), Cox reminded coders that the visit must meet two of these requirements:

Report separate E/M: According to Cox, here are two instances when you might be able to report a separate 99212-25 along with a procedure code:

• An established patient comes in for a shoulder injection. During the examination, the provider discovers ringworm on the patient’s arm and a performs separate, straightforward MDM to address the ringworm.
• An established patient reports with shoulder pain and is the provider performs an injection. The provider then orders an X-ray, which will not be billed by the provider, to make sure there is no need for surgery, checks for other pathologies, and writes a script for physical therapy (PT). Notes indicate that the E/M time not associated with the injection totaled 16 minutes.

Do not report separate E/M: According to Cox, here are two instances when you cannot report a separate 99212-25 along with a procedure code:

• An established patient comes in for a knee injection. The provider examines patient, declares them approved for injection, and performs the injection.
• An established patient comes in with shoulder pain and is given an injection. An X-ray is also reviewed, which will be billed by the provider.