General Surgery Coding Alert

Hint: You can use the same diagnosis to justify an E/M and a procedure

The AMA will provide a helpful clarification on when to append modifier 25 in CPT 2006, but if you-re seeking still more on how to ace your modifier 25 claims, here are three surefire tips.

1: Report Only -Significant- Services
 
To gain separate payment for an E/M service the physician provides at the same time as another procedure or service, the E/M service 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 E/M service the surgeon provides that normally accompanies a procedure, says Barbara J. Cobuzzi, MBA, CPC, CPC-H, CHBME, president of CRN Healthcare Solutions, a coding and reimbursement consulting firm in Tinton Falls, N.J.

Example: The patient arrives for a previously scheduled diagnostic endoscopy (43235, Upper gastrointestinal endoscopy including esophagus, stomach and either the duodenum and/or jejunum as appropriate; diagnostic, with our without collection of specimen[s], by brushing or washing [separate procedure]). The surgeon provides a cursory exam to assess the patient's fitness for the procedure. In this case, the exam, history and medical decision-making (MDM) does not exceed a level-two E/M service (99212), and therefore the service does not qualify as significant.

Extra tip: -I ask myself, -Can I find in the notation a clear history, exam and medical decision-making?- If so, I-ve got a separately 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.

2: Document the E/M Service Separately

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 other procedure(s) or service(s) the surgeon provides. This demonstrates to the payer the E/M service's distinct nature, Jandroep says.

Here's how: The surgeon should document the history, exam and MDM in the patient's chart and record the procedure notes on a different sheet attached to the chart.

The AMA weighs in: For 2006, CPT will specify, -a significant, separately identifiable E/M service is defined or substantiated by documentation that satisfies the relevant criteria for the respective E/M service- you choose to report.

3: Always Include a Dx for the E/M

When reporting any E/M service, you must link the service to a diagnosis that explains the reason the physician performed the service.

Important: The E/M service needn't be unrelated to the other service(s) or procedure(s) the physician provides on the same day, Cobuzzi says. CPT specifically states, -The E/M service may be prompted by the symptom or condition for which the procedure and/or service was provided. As such, different diagnoses are not required for reporting of the E/M services on the same date- [emphasis added].

Example: A new consult patient arrives with a complaint of intense heartburn and abdominal pain. The surgeon takes a complete history and performs an extensive exam. She then performs diagnostic endoscopy to check for reflux disease.

In this case, you will report the endoscopy (43200, Esophagoscopy, rigid or flexible; diagnostic, with or without collection of specimen[s] by brushing or washing [separate procedure]). Separate documentation will also support a level-three outpatient consult, to which you should append modifier 25 (99243-25).

You should link the signs and symptoms that prompted the exam (787.1, Heartburn and 789.00, Abdominal pain; unspecified site) to the E/M code. You can link the same signs-and-symptoms diagnoses to the endoscopy. Or, if the surgeon finds verifiable evidence of reflux disease (530.xx), you can report that diagnosis as primary with the signs and symptoms as secondary.