E/M on Same Day as Minor or XXX Procedure
The rules related to reporting 99201-99215 on the same date as a minor procedure are confusing for many coders. You need to understand which services the payer considers separately reportable.
A minor surgical procedure is a procedure with a global period of 0 days or 10 days on the Medicare Physician Fee Schedule (MPFS). Many payers other than Medicare use this definition, as well. The global period refers to the length of time the global surgical package applies.
The basic idea of the global surgical package is that services normally performed by a provider before, during, and after a procedure are included in the surgery code instead of being reported separately. All those usual services get factored into the payment rate for the surgical code, so reporting those usual services separately would result in being paid twice for the same service. Payers scrutinize this area of coding to ensure they aren’t overpaying.
Medicare’s definitions of the 0-day and 10-day global periods, available in the MPFS relative value files, indicate that Medicare usually does not pay for E/M services during the global period (bold added for emphasis):
- 0-day global period: “Endoscopic or minor procedure with related preoperative and postoperative relative values on the day of the procedure only included in the fee schedule payment amount; evaluation and management services on the day of the procedure generally not payable.”
- 10-day global period: “Minor procedure with preoperative relative values on the day of the procedure and postoperative relative values during a 10 day postoperative period included in the fee schedule amount; evaluation and management services on the day of the procedure and during the 10-day postoperative period generally not payable.”
One reasons E/M codes during the global period are “generally not payable” is that Medicare considers a decision to perform a minor surgery made immediately before the procedure to be a routine preoperative service, according to Medicare Claims Processing Manual, Chapter 12, Section 40.2.A.4. Additionally, a certain amount of history-taking and physical exam work, as well as follow-up care, is expected for a minor procedure, so the surgical code includes payment for that work.
But the phrase “generally not payable” in the global period definitions leaves room for reporting E/M codes separately under certain circumstances. The rule is that you may report significant, separately identifiable E/M services on the same day as a minor procedure. Medicare provides the example of reporting an E/M code for a full neurological examination on the same date that you report a code for suturing a scalp wound for a patient with head trauma. But you need to ensure documentation supports reporting a distinct E/M service. “Billing for a visit would not be appropriate if the physician only identified the need for sutures and confirmed allergy and immunization status,” states Medicare Claims Processing Manual, Chapter 12, Section 40.1.C.
If documentation does support reporting an E/M code on the same date as a minor procedure code, you should append modifier 25 to the E/M service code to acknowledge that special circumstances make the code reportable.
The National Correct Coding Initiative (NCCI) Policy Manual for Medicare Services, Chapter 1, states that providers also may submit a distinct E/M code with modifier 25 on the same date as a code that has an XXX global indicator. The XXX indicator means the global concept does not apply to the code.
Again, for you to report the E/M separately, it must be distinct from the typical pre-, intra-, and post-procedure work for the XXX-global code. That means you should not report an E/M for the physician’s supervision of someone else performing the procedure or interpretation of the result of the procedure.
Note that both Medicare and CPT® state that you do not need different diagnoses for the distinct E/M service and the procedure. But experts advise that separate diagnoses may help show that the E/M was significant and separately identifiable from the surgery. You should not report separate diagnoses simply to improve your chances for payment, however. Always base your ICD-10-CM coding choices on the documentation and follow proper coding rules.