Continuous Glucose Monitoring and E/M on the same DOS

jenarnold

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Hi Everyone,
I'm working with an Endocrinologist who performs CGM (Continuous Glucose Monitoring) using CPT 95251 and also wants to bill an E/M. The provider is having some trouble understanding the 25 modifier guideline despite a few different explanation approaches. I am seeking some words of wisdom on how to explain this in a better way. Also, I would like any feedback on my billing suggestion to the provider (last sentence). Are there rules against not billing a procedure but instead include it in the E/M MDM or time? Thank you in advance for reading and responding.

The basics of the coding situation are: The E/M code, 99215-25, was billed in addition 95251. The conditions are T1DM and polyneuropathy. 99215 was billed based on time of 61 minutes.

One of my explanations was: "The reimbursement for 95251 includes the inherent pre-procedure, intra-procedure, and post-procedure work usually performed each time the procedure is completed. This means that we cannot separately bill an E/M for the same work that is already included in the reimbursement for 95251.
99215 cannot include any work related to the diagnosis of T1DM or 95251. The E/M can only include the work for other conditions that are significant and separately identifiable from the CGM service and T1DM. Or, in other words, the E/M can only be billed separately on the same day when a significant and separately identifiable service took place above and beyond the services associated with CGM. In this case, the only other condition was polyneuropathy, which by itself doesn't support 99215 based on MDM.
My suggestion is to bill 95251 and separately bill the appropriate level of E/M with a 25 modifier for the polyneuropathy. Or, bill 99215 alone without 95251."

Thank you again for reading and responding,
Jen
 

thomas7331

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You are citing the modifier 25 guidelines but I'm afraid I disagree with what you are telling the provider here because I don't think you are using the guidelines in a correct context. First of all, 95251 does not represent a procedure - it is the interpretation and report of a non-invasive diagnostic test. There is no "inherent pre-procedure, intra-procedure, and post-procedure" E/M work involved in interpreting results of the test as there would be in performing a surgical procedure that always has to include an evaluation of the patient. In addition, there is no CCI relationship between 95251 and any E/M service, so in theory at least, no modifier 25 is even necessary or required in order to bill these two codes together.

Per the new 2021 E/M guidelines, since the provider is billing separately for the interpretation and report, it should not be included in the calculation of the MDM for the level, and the time spent for the I&R cannot be counted toward the total time. However, there is no other restriction from billing these two codes together, and the provider should get full credit for their E/M with the patient treating any and all of the conditions addressed and for all face-to-face time exclusive only of the time spent performing the I&R itself.
 

vinessachilders

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I find it easier for my providers to understand if I put it in simple terms. I let them know they cannot bill for an E&M and a procedure for the same chief complaint or condition. My providers seem to understand that wording better than "related to the diagnosis". If they are billing a 95251, AMA states the patient does not need a face-to-face visit; so to bill for a face-to-face visit, the patient must have a separate/different chief complaint. Since the patient's polyneuropathy was addressed, I would tell the provider to bill for the 95251 and use MDM (for that condition only, if diabetes was not addressed during the E&M portion of the visit) to support the separate E&M (with modifier 25).

Modifier guidelines still apply, according to this article from Medtronic:
 

jenarnold

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You are citing the modifier 25 guidelines but I'm afraid I disagree with what you are telling the provider here because I don't think you are using the guidelines in a correct context. First of all, 95251 does not represent a procedure - it is the interpretation and report of a non-invasive diagnostic test. There is no "inherent pre-procedure, intra-procedure, and post-procedure" E/M work involved in interpreting results of the test as there would be in performing a surgical procedure that always has to include an evaluation of the patient. In addition, there is no CCI relationship between 95251 and any E/M service, so in theory at least, no modifier 25 is even necessary or required in order to bill these two codes together.

Per the new 2021 E/M guidelines, since the provider is billing separately for the interpretation and report, it should not be included in the calculation of the MDM for the level, and the time spent for the I&R cannot be counted toward the total time. However, there is no other restriction from billing these two codes together, and the provider should get full credit for their E/M with the patient treating any and all of the conditions addressed and for all face-to-face time exclusive only of the time spent performing the I&R itself.
Thank you, I appreciate the feedback. I believe I understand the XXX and why the 25 modifier isn't required. What I understand now is that 95251 isn't for all the work associated with the T1DM condition, it is simply the interpretation and report of the glucose monitoring only. Therefore, a separate E/M could be billed for all the counseling and MDM work for the T1DM.
 
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