Gastroenterology Coding Alert

Separate documentation must stress the distinct nature of the E/M

If you fail to report a legitimate, separately identifiable E/M service, your practice misses out on anywhere from $25 to well over $100. Don't let this happen to you: Here are three ways to be sure that you apply modifier 25 correctly for separate E/M services. Significance Is Key for Separate E/M To gain payment for an E/M service the physician provides at the same time as another procedure or service, the E/M must be both significant and separately identifiable.
 
All procedures, from simple injections to common diagnostic tests, include an -inherent- E/M component, according to CMS guidelines. Therefore, any E/M service you report separately must be -above and beyond- the minimal evaluation and management that normally accompanies such a procedure, says Marcella Bucknam, CPC, CCS, CPC-H, CCS-P, HIM program coordinator at Clarkson College in Omaha, Neb.

But modifier 25 is not restricted to a particular level of service, according to CPT Assistant, September 1988.

Example: The gastroenterologist provides a cursory examination prior to a previously scheduled procedure, such as upper GI endoscopy (43235, Upper gastrointestinal endoscopy including esophagus, stomach, and either the duodenum and/or jejunum as appropriate; diagnostic, with or without collection of specimen[s] by brushing or washing [separate procedure]).

In this case, the simple -preprocedure- exam is neither significant nor separately identifiable, and therefore you should not attempt to report it separately.

Tip: -I recommend that coders do the -HEM- test--can you pick out from the documentation a clear history, exam and medical decision-making apart from any other procedures the physician performs on the same day. If so, you-ve probably got a billable service- with modifier 25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service), says Laureen Jandroep, OTR, CPC, CCS-P, CPC-H, CCS, director and senior instructor for CRN Institute, an online coding certification training center based in Absecon, N.J.

Bottom line: You should consider a brief history and physical prior to a same-day scheduled outpatient procedure as an included component of the procedure itself.

Even if the physician provides an assessment and plan, you probably should not report a separate E/M service unless the patient has a new, unrelated complaint or has experienced a worsening of symptoms that prompts a new history, exam and medical decision-making process that might include additional testing or therapy. Keep E/M Documentation Apart  When reporting an E/M service on the same day as another procedure, physically separate the documentation for the E/M portion of the service from the procedure documentation. This demonstrates to the payer the E/M service's distinct nature, Jandroep says.

The physician should document the history, exam and medical decision-making in the patient's chart and record [...]