Neurology & Pain Management Coding Alert

Remember, not all preprocedure services constitute a separate E/M If your neurologist performs an E/M service and a procedure on the same patient during the same encounter, you may be able to report the E/M using modifier 25 (Significant, separately identifiable E/M service by the same physician on the same day of the procedure or other service). Or you may not. The key: You must prove that the E/M is a separate service and is not an inherent component of the procedure. Follow this advice to find out when to report an E/M with modifier 25, and when to leave the E/M off the claim. Find Evidence of Separate E/M in Notes In a nutshell: "Coders should use modifier 25 when a significant, separately identifiable E/M service is performed by the same physician at the same face-to-face encounter as a procedure or other service," says Catherine Brink, CMM, CPC, president of Healthcare Resource Management of Spring Lake, N.J. The most vital element on successful modifier 25 claims is concrete evidence that the procedure and E/M were truly separate, Brink says. All procedure codes have an inherent E/M component built into them, and the physician must go beyond that to justify a separate E/M. In addition, the E/M service must also meet medical necessity criteria -- if it doesn-t, you should just report the procedure code. Exam Must Go Beyond -Limited-
Now check out this detailed scenario, courtesy of Brink, in which the physician performs a procedure and a separate E/M: A new patient presents with dull aching pain in his right elbow. The pain has persisted for three weeks, and despite taking Motrin for the pain, he's gotten no relief. The patient is a tennis player, and he reports that the elbow gets worse after he plays tennis or when he makes a fist. The neurologist performs a review of systems; past, family and social history; an expanded problem-focused history and an expanded problem-focused exam on the right elbow, which reveals trigger point at lateral epicondyle of the humerus. When the physician depresses the elbow, the patient has pain radiating to the outer side of his arm and forearm aggravated by dorsiflexion and supination of the wrist. When his middle finger is extended against resistance, the pain is worse. The patient has no numbness or tingling in the elbow. During the course of moderate medical decision-making (MDM), the physician makes a diagnosis of lateral epicondylitis (tennis elbow) and injects 1 mg of cortisone into the elbow. The physician advises the patient to use a tennis elbow strap when lifting with his right arm and while playing tennis. In this instance, the physician performed a significant E/M service before deciding to [...]