Neurology & Pain Management Coding Alert

Separate documentation must stress the distinct nature of the E/M service Revised explanatory text for modifier 25 in CPT 2006 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. Here are three ways to ensure that your documentation is up to the task. 1. Stress -Significance-  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.

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 CRN Healthcare Solutions, a coding and reimbursement consulting firm in Tinton Fall, N.J.

Aim for level three or higher: Although CPT does not provide precise guidelines to define -significant,- many coding experts suggest that the physician should document at least a level-three service for an established patient (99213 or higher) before charging for a separate E/M.

Example: The neurologist provides a cursory examination prior to a previously scheduled electro-myographic (EMG) exam for upper-extremity weakness and pain. In this case, the exam alone does not exceed a level-one E/M service (99211), and therefore the service does not qualify as significant.

Tip: -I always ask, -Can I find in the documentation a clear history, exam and medical decision-making?- If so, I-ve 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. 2. Physically Separate the E/M Documentation When reporting an E/M service on the same day as another procedure, physically separate the documentation for the E/M. 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 the procedure notes on a different sheet attached to the chart. 3. Choose an E/M Diagnosis 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, [...]