Neurology & Pain Management Coding Alert

4 steps put you on the path to better reimbursement

Modifier -25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) can be your best friend when reporting an E/M service on the same day as a procedure or other service, preventing payers from shortchanging you on valuable reimbursement dollars.

Don't let this happen to you! A new patient arrives for a consult with the neurologist with a possible diagnosis of carpal tunnel syndrome (354.0). The neurologist provides a full E/M service, spending about 40 minutes taking the patient's history, performing an exam and, finally, deciding to conduct several electrodiagnostic tests, including electromyogram (EMG) and nerve conduction study (NCS), which she administers during the same visit.

To report the visit, you claim the appropriate test codes (for example, 95860, Needle electromyography; one extremity with or without related paraspinal areas and 95900, Nerve conduction, amplitude and latency/velocity study, each nerve; motor, without F-wave study), along with 99243 (Office consultation for a new or established patient ...) for the E/M service. But when the payer returns your claim, you notice that it has refused payment for the consult, shortchanging your practice over $100 for a service properly rendered and documented.
If you want to avoid such expensive lessons, follow these four points for billing E/M services with other procedures on the same day. First: Be Sure the Service Is Significant To be paid separately, any E/M service you bill at the same time as another procedure must be significant and separately identifiable.

CMS policy dictates that all procedures, from simple injections to common diagnostic tests, include an inherent E/M component. Therefore, any E/M service you report separately must be above and beyond the E/M service the physician normally provides as a part of the procedure billed, says Barbara J. Cobuzzi, MBA, CPC, CPC-H, CHBME, president of Cash Flow Solutions Inc., a reimbursement consulting firm recently relocated to Brick, N.J. Significance is particularly important for E/M services provided at the same time as a diagnostic test (such as EMG, NCS, etc.) because the "included" pretest evaluation is not very substantial. Documentation should indicate that the physician provided a significant service and demonstrate that "double-dipping" has not occurred.

Aim for level-three or higher: Although CPT does not provide precise guidelines to define "significant," coding experts generally agree that the physician should document at least a level-three service before charging for a separate E/M. For example, the physician provides a cursory examination because of a new patient complaint during a previously scheduled procedure. In this case, the exam by itself does not exceed a level-one or -two E/M service (e.g., 99211 or 99212), so the service is not [...]