Internal Medicine Coding Alert

Published on Thu Jan 28, 2010 PDF

Question: Our internist recently treated gastrointestinal upset during a well-woman visit. Will Medicare accept an E/M code along with the screening code for this service?

New York Subscriber

Answer: Physicians are allowed to file an E/M (99201-99215) along with well-woman examination  codes, but only if the internist treats a problem "significant enough to require additional work to perform the key components of a problem-oriented E/M service," according to CPT.

Modifier 25 defined: Append modifier 25 only when you identify a "significant, separately identifiable E/M service by the same physician on the same day of the procedure or other service."

Tip: Indicate how the patient's condition required a significant, separately identifiable E/M service above and beyond the other service provided or beyond the usual preoperative and postoperative care associated with the procedure that the internist performed. To meet the modifier 25 standard, you must substantiate the claim with documentation that satisfies the relevant criteria for the respective E/M service. Different diagnoses are not required for reporting of the E/M services on the same date.

Example 1: The internist performs a screening pelvic examination and a screening Pap test during the same encounter, offers the Medicare Preventive Services Guide (p. 117). When this happens, list both procedure codes as separate line items on the claim. You may report a covered E/M visit and Q0091 (Screening papanicolaou smear; obtaining, preparing and conveyance of cervical or vaginal smear to laboratory) for the same date of service if the E/M visit is for a separately identifiable service. In this case, report modifier 25 with the E/M service and ensure that the medical records clearly document the E/M service reported. Also, list both procedure codes as separate line items on the claim.

Example 2: The internist is performing a well-woman exam for an established Medicare patient. During the visit, the patient mentions an aching shoulder. The physician orders an additional workup and writes a prescription. In this instance, you can report a separate E/M.