Otolaryngology Coding Alert

On March 27, 1998, Terrence L. Kay, the director of HCFAs division of practitioner and ambulatory care, sent the following letter to Lee Eisenberg, MD, clarifying HCFAs position on evaluation and management (E/M) services performed the same day as procedures and the use of modifier -25.

Dear Dr. Eisenberg:

I am responding to your letter to Barton McCann, MD, concerning Medicare payment for a procedural service and evaluation and management service on the same day. Payment under the Medicare physician fee schedule is based on the relative resources or work involved in providing a service. If a patient visits a physician for a minor procedure (e.g., a minor surgery or an office-based endoscopy) and receives no other services, the physician may only bill for the procedure, and may not also bill for an office visit since no other services were provided.

If in addition to the procedure the physician also provides significant separately identifiable evaluation and management services beyond the usual preoperative and postoperative services associated with the procedure, such services should be billed with modifier -25 and are separately payable. The evaluation and management service does not have to be unrelated to the procedure and the same diagnosis is not sufficient reason to deny payment for the evaluation and management service.
Sincerely,

Terrence L. Kay
Director, Division of Practitioner and Ambulatory Care