ED Coding and Reimbursement Alert

Question: When is it appropriate to code an initial E/M (for a new patient) without the -25 modifier when a procedure is performed on the same day? Please comment on the minor procedures versus the global. I would appreciate clarification on the difference between CPTs rules and HCFAs rules.

Ohio Subscriber

Answer: ED visits do not distinguish between new or established patients or initial or subsequent services. According to CPT, minor procedures do not include the pre- or postoperative service. Therefore, the examination to identify the injury and type of operative procedure to be performed is a separate service.

Medicare, however, includes the related pre- and postoperative service in the procedure package unless it is significant and separately identifiable. If so, the -25 modifier (significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) is affixed to the E/M code and the procedure is billed as well. Although CPT provides one additional code, 99025, its use with initial visit at the time of a procedure has ruled out its use for ED visits, according to past AMA clarifications.

A starred procedure does not have a pre- and postoperative component added in to the total relative value units. Therefore, the global package does not apply. When a starred procedure is performed at the time of an initial or established visit involving significant identifiable services, the appropriate E/M code with the -25 modifier appended would be billable in addition to the starred procedure. Make sure the physicians documentation supports both services.

In the Medicare Fee Schedule, minor procedures have a global period of zero days or 10 days. Services with zero global days include the procedure only. Procedures with 10-day global periods include the procedure and a 10-day postoperative period. The postoperative period includes any services related to the original procedure (i.e., suture removal), which may not be billed separately.

Most major procedures have a 90-day global period, for which the same coding policy applies.

HCFA does not necessarily follow CPT guidelines set by the AMA. HCFA is the controlling factor in Medicare policies, which are somewhat different. According to CPT, the day before a surgery is not included in the global package and is separately billable. According to Medicare, however, anything 24 hours before surgery is global.


Reader Questions answered by Lorraine A. Began, CPC, billing compliance monitor, The Metrohealth System, Cleveland; Caral Edelberg, CPC, CCS-P, president of Medical Management Resources Inc., an emergency department coding consulting firm in Jacksonville, Fla.; John Turner, MD, PhD, medical director for documentation and coding, healthcare financial services at TeamHealth, an ED staffing firm in Knoxville, Tenn.; Michael Granovsky, MD, chief financial officer of Greater Washington Emergency Physicians, a five-physician group staffing a 24,000-visit ED, Maryland; Mason A. Smith, MD, FACP, CEO Lynx Medical Systems, Bellevue, Wash; and Bart Hershfield, MD, FACEP, reimbursement committee chair of the West Virginia American College of Emergency Physicians (ACEP).