# E&M with procedure code



## ValerieDUP! (May 27, 2010)

If a NEW patient makes an appointment to have a lesion looked at and during the same visit the doctor decides to remove it can we bill for both the initial E&M code and the removal code?


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## sbicknell (May 27, 2010)

If he does both the same day, then no. Can't code an E&M unless he does something separate and in addition to removing the lesion that would support the use of mod -25

But if the patient comes in and says I want this taken off, the phsyician looks at it and says yea, we'll just do a simple shave and then takes it off, then there is nothing to support a "significant separate E&M service"


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## cheermom68 (May 27, 2010)

*lesion*

I disagree.  If the patient comes in and the physician does the workup and documentation necessary for a new patient visit and decides to remove the lesion at that time, you can bill the office visit and the lesion removal.  However, if the lesion had previously been looked at and they knew it had to be removed then no E&M would be charged.


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## abash (May 27, 2010)

I agree with cheermom. If the lesion removal had been planned prior to the visit, the E/M code could not be billed. Since it wasn't planned beforehand, it is okay to bill for both the E/M and the removal.

-Amy


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## sbicknell (May 27, 2010)

The fact that the patient is new does not effect the mod -25 issue. 

The poster said the patient came in to have a lesion looked at. If the physician does a SF skin exam and said yea, let's shave it, then all that can be coded is the CPT code

If the physician said I am also going to do a full physical cause that's what I do for every new patient, then that brings up the issue of medical necessity. The patient asked for a specific service and had no other complaints. The physician can't just do a new patient work-up with a full detailed/comp exam just cause "that's what he always does".

This is a paste from CMS/Trailblazer.  See Point #3 and the areas I have highlighted

_*The following conditions must be met to report modifier 25:*

  *The patient's condition required a significant, identifiable E/M service above and beyond *the other service provided or *services beyond the usual preoperative and postoperative care *associated with the procedure that was performed.

  These circumstances may be reported by adding the 25 modifier to the appropriate level of the E/M service.

In the conditions above, the bold areas indicate the key phrases for the proper use of the modifier.
1.  The phrase, “the patient's condition required” is extremely important. In other words, it was medically necessary for the patient to have these extra services on the same day that another procedure or service was performed.

2.  The phrase, “a significant, separately identifiable E/M service above and beyond” the other service provided indicates that this extra service was clearly different from the other procedure or service that was performed.

3.  The phrase, “services beyond the usual preoperative and postoperative care” associated with the procedure emphasizes the fact that all procedures as defined in the Resource-Based Relative Value Scale (RBRVS) system of reimbursement that Medicare uses include a certain amount of preoperative and postoperative care in the reimbursement package. The 25 modifier should be used if extra work beyond the usual is performed. A good standard for judging whether the 25 modifier should be used is: If a physician in the same specialty area would agree after reading the clinical record that extra preoperative and/or postoperative work beyond what is usually performed with that service was performed, then it is proper to use the 25 modifier to indicate that extra work. To document the extra work performed, the clinical record should clearly indicate that extra or unusual work.

Primary considerations for modifier 25 usages are:
 Why is the physician seeing the patient?
o  If the patient exhibits symptoms from which the physician diagnoses the condition and begins treatment by performing a minor procedure or an endoscopy on that same day, modifier 25 should be added to the correct level of E/M service.

o If the patient is present for the minor procedure or endoscopy only, modifier 25 does not apply.

o  If the E/M service was to familiarize the patient with the minor procedure or endoscopy immediately before the procedure, modifier 25 does not apply.

  If the E/M service is related to the decision to perform a major procedure (90-day global), modifier 25 is not appropriate. The correct modifier is modifier 57, decision for surgery.

  When determining the level of visit to bill when modifier 25 is used, physicians should consider only the content and time associated with the separate E/M service, not the content or time of the procedure.

Examples of *Proper Use *of the 25 Modifier
Example 1: A patient has a nosebleed. The physician performs packing of the nose in the office, which stops the bleeding. At the same visit, the physician then evaluates the patient for moderate hypertension that was not well controlled and adjusts the antihypertensive medications.
The 25 modifier may be reported with the appropriate level of E/M code in addition to the minor procedure. The hypertension E/M was medically necessary, significant and a separately identifiable service performed on the same day as control of the nosebleed. The hypertension was exacerbating the nosebleed and was actually related to the nosebleed, but management of the hypertension was a separate service from actually packing the nose.

Example 2: A patient presents to the physician with symptoms of urinary retention. The physician performs a thorough E/M service and decides to perform a cystourethroscopy. Cystourethroscopy is performed the same day as the E/M code.
The 25 modifier may be reported with the appropriate level of E/M code in addition to the cystourethroscopy. The physician had to evaluate the patient based on the symptoms and decides on the procedure to be performed. The procedure was then performed on the same day as the E/M.

Examples of *Improper Use *of the 25 Modifier
*Example 1: A patient has a small skin cancer of the forearm removed in the physician's office. This is a routine procedure and no other conditions are treated.
The office visit is considered part of the surgery service and, therefore, not separately reimbursable. The use of the 25 modifier is inappropriate. Only the surgical procedure should be reported.*

Example 2: A patient visits the physician on Monday with symptoms of GI bleeding. The physician evaluates the patient and bills an E/M service. The physician tells the patient to return on Wednesday for a sigmoidoscopy. On Wednesday, a sigmoidoscopy is performed in a routine manner.
An E/M service (no modifier applied) may be billed for the service provided on Monday. However, a separate E/M service should not be reported for Wednesday when the patient returned for the sigmoidoscopy.

Key Points
  Both the medically necessary E/M service and the procedure must be appropriately and sufficiently documented by the physician/practitioner in the patient's medical record to support claims for payment of the E/M service and the available if requested by the carrier.

  The 25 modifier should be used to designate a significant, separately identifiable E/M service provided by the same physician/practitioner on the same patient on the same day as another procedure or service with a same-day or 10-day global period.

* The 25 modifier identifies a significant, separately identifiable E/M service. It should be used when the E/M service is above and beyond the usual pre- and postoperative work of a procedure with a same-day or 10-day global fee period performed on the same day as the E/M service.*

 Different diagnoses are not required for reporting the E/M service on the same date as the procedure or other service with a global fee period. Modifier 25 should be added to the E/M code on the claim._


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## cheermom68 (May 27, 2010)

*lesion removal*

We would have to see the documentation to make an informed decision.  But just because the patient wanted the lesion looked at would not preclude an office visit.  Since it is a new patient I would think that the physician would want to get a complete history (detailed at the least) before performing a procedure.  They would have an EPF exam with just the vitals and skin exam, the MDM points could be low with a new problem, this could equate to a 99202, if the appropriate documentation is there.  Since the physician has to make the decision to remove the lesion,  with appropriate documentation, I would have no problem charging the office visit.


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## sbicknell (May 27, 2010)

You're the only one that knows what your documentation supports but here is a good rule of thumb.

If you took away all the documentation addresssing the lesion, would you have enough to support a separate E&M code? Is the physician evaluating anything other than the lesion? What does the documentation support?

If not, then there is no significant separate E&M work performed. The eval of the lesion-whether for a new or est patient--is considered pre-procedure work

An auditor will quickly flag encounters that full evals are done on every new patient walking in the door just cause "thats what we do". 

The argument of "but this is a new patient, I cant just do a procedure on a patient I have never seen " became invalid long ago. Here is a paste from CMS

_Furthermore, Medicare Global Surgery rules prevent the reporting of a separate E&M service for the work associated with the decision to perform a minor surgical procedure whether the patient is a new or established patient. _


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## cheermom68 (May 27, 2010)

*lesion*

This can be a gray area.   I think the distinction between the patient coming in because "I want this taken off" and "I want this looked at"  are important.
Per CMS

The
E/M service may be prompted by the symptom or condition for which the
procedure and/or service was provided. As such, different diagnoses are not
required for reporting of the E/M services on the same date. 

Per above, there doesn't need to be a different condition looked at to qualify for the 25 modifier.


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## sbicknell (May 27, 2010)

It can't be any more clear than this:

_Furthermore, Medicare Global Surgery rules prevent the reporting of a separate E&M service for the work associated with the decision to perform a minor surgical procedure whether the patient is a new or established patient. _


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## cheermom68 (May 27, 2010)

*Lesion*

I believe it depends on who the payer is.  CPT seems to state that it is okay, (and possibly commercial payers) however CMS disagrees.  It seems that CMS is contradicting themselves by saying that the E&M and procedure can be for a related problem but then says that you can't bill for it.


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## alosiewski (Jan 29, 2013)

I agree that the E&M should not be coded.  I feel the CPT manual makes it fairly clear if you read the surgery guidelines that the E&M code is part of the global package.  It is frustrating because most providers want to be reimbursed for the office visit or exam as well because they feel the work has been completed.  But I really do feel it is part of the procedure package.


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