Wiki Inpatient E&M question - Subsequent visit with 25 modifier on day of scope??

[bailsb]

Hi All,

I’ve been coding for a long time now, well over a decade. I have coded thousands of GI charts. Most of these are inpatient. When the GI MD initially sees the pt, say for a suspected GI bleed and anemia, with a decision for EGD and Colonoscopy, if the documentation supports it I will code an E&M with a 25 modifier and the scopes. Recently I was asked to code a site I don’t normally code. I have been in there for about a week and now I am getting rebuttals where I did NOT give a subsequent visit E&M with a 25 on the day of an EGD or colonoscopy. In all my years I have never given this unless the documentation supports with a very sick pt being seen for many ailments supports E&M with 25 on day of scopes. It is very very rare, if ever, I would code this.

Low and behold I noticed the coder I am filling in for has been giving the subs with 25 on day of scopes. EXAMPLE: 99232-25 and 43239 on same DOS. The coder is much younger than me so I am concerned they are aware of some new ruling that I have overlooked. Hence, I am posting this for the forums expert advice

Are these rebuttals warranted or is the coder I’m filling in for incorrect? I strongly feel a 25 modifier is not supported on day of scope unless initial visit/consult with decision for scope(s).

Thank you.

 

[thomas7331]

Well, as you correctly state, the E/M with the modifier is only appropriate if the documentation supports it. I have not coded as many of this particular kind of chart as yo have, and don't know how your particular providers are documenting anyway. Without seeing the charts you're looking at, it's really hard to say one way or the other. I would say, though, that I don't think I would use the strict criteria you're using here that for the subsequent visit the patient must be 'very sick' and with 'many ailments'. Per the guidelines, the 25 modifier is appropriate if the E/M that's documented on the same day has separate and significant work that is unrelated to the procedure. So the criteria I would lean towards is that if the provider is managing patient conditions above and beyond the usual pre- and post-operative work the endoscopy, as described in the global package, then I would think the modifier could be justified. If they are simply checking on the patient and going over results or writing a prescription related to the findings of the procedure and/or signing off, then no, I wouldn't code the E/M service.

 

[bailsb]

I appreciate your response. Yes, most of the time it just a quick check up explaining the upcoming procedure or a follow-up going over the results. On very rare occasions is the GI MD separately treating something that is not already being addressed by IM, PULM, Cards, etc which makes it very hard to justify a separate E&M with 25. I appreciate you taking the time to look at this. Thank you.

 

[thomas7331]

I appreciate your response. Yes, most of the time it just a quick check up explaining the upcoming procedure or a follow-up going over the results. On very rare occasions is the GI MD separately treating something that is not already being addressed by IM, PULM, Cards, etc which makes it very hard to justify a separate E&M with 25. I appreciate you taking the time to look at this. Thank you.

You're welcome. I appreciate the difficulty and have been in that situation. It's always hard when one coder has been generous in allowing physician to bill something and then another coder has to come in an explain why it's being taken away. No fun. Hopefully you will have some support from your management.