Wiki E/M Emergency Physician with procedure

[williak]

I code ER facility and now new to coding ER professional fee. I know on the facility side you can code an E/M level with Mod 25 for a procedure, say a laceration repair. But I'm getting mixed info on if you can code the E/M with a laceration repair for the physician fee/billing in the ER. Since nearly every ER visit the patient is new it would seem that the E/M would always be coded because each patient has to be evaluated and history taken before any decision is made for tests and/or treatment. So my senario would be: patient comes in to ER with a finger laceration. The doctor examines and evaluates the patient and repairs the laceration and sends patient home. would it be correct to code the laceration repair and the E/M level with Mod 25????? Please advise!! Thanks much!

 

[OCD_coder]

Per the NCCI Policy Manual, the criteria for modifier 25 needs to have supporting documentation of a significant, separate E&M service. A minor procedure has preoperative evaluation included in the work of the procedure. This means a brief E&M=pre-procedure evaluation, so if the provider does a more extensive History and Exam they need to document why it was indicated. Your example seems straightforward and not really significant from pre-procedure work, based on the information from CMS I would be hard pressed to support a separate E&M. There is no specifically published information that ED profee services should be considered differently, just because you can report a separate E&M with a modifier 25, doesn't mean you should; it all depends on what the documentation supports. But I remain open for additional information on that issue.

NCCI Policy Manual, Chapt 1, General Correct Coding Policies, page I-17, final 2014
....the minor surgical procedure is separately reportable with modifier 25. The E&M service and minor surgical procedure do not require different diagnoses. If a minor surgical procedure is performed on a new patient, the same rules for reporting E&M services apply. The fact that the patient is “new” to the provider is not sufficient alone to justify reporting an E&M service on the same date of service as a minor surgical procedure. NCCI contains many, but not all, possible edits based on these principles. 1 General

 

[knorris67]

You can absolutely bill for the laceration repair with the E/M. However, a modifier -25 shoud not be appended because the reason for the ER visit was the finger laceration. In this case the repair is not an incidentally separate service. I agree with the previous post on the use of modifier -25.