Reader Question: Technical and Professional Fees

Question: Currently, we assign evaluation and management (E/M) level codes to the professional and technical side of the emergency department (ED). When APCs arrive, will there be times when an E/M level for the technical side is not assigned? For example, a patient comes in with a laceration to the knee, and the physician sutures the laceration. Currently, we assign an E/M level for the technical side. With the advent of APCs, should we only be assigning a procedure code and no E/M? What if the physician repairs a laceration and orders a CT scan on a child who falls from his bike, sustains a laceration and complains of dizziness? Do we assign an E/M level with modifier -25 (significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) and a procedure code?

Connecticut Subscriber

Answer: In the first scenario, unless the physician mentions other potential injuries aside from the laceration, or if he or she feels that it is necessary to identify additional underlying medical problems that might complicate treatment, you probably would identify only the laceration repair code and not the facility assessment level (E/M).

In the second example, other problems outside the area of injury need to be addressed, and the E/M code (with modifier -25 to designate the E/M service as significant and separately identifiable) would be billed in addition to the laceration repair. In general, when the E/M level qualifies for a -25 modifier, it should be billed in addition to the procedure. When it doesnt, you would bill either a procedure or the E/M code, but not both. Although we still dont have a clear interpretation of significant from the Health Care Financing Administration, we should see something within the year to ensure that coding for services qualifying for the -25 modifier isnt abused.

- Published on 2000-08-01