ED Coding and Reimbursement Alert

Significance, separation, and selection will lead you to success

Modifier -25 can be your best friend when reporting an evaluation and management (E/M) service on the same day as a procedure or other service, preventing payers from shortchanging you on valuable reimbursement dollars. But to use the modifier correctly, you must be sure that documentation supports your claim for a separate, significant E/M service.

First: Be Sure the Service Is Significant 

To be paid separately, any E/M service you bill at the same time as another procedure must be significant and separately identifiable.
 
CMS policy dictates that all procedures, from simple injections to common diagnostic tests, include an inherent E/M component. Therefore, any E/M service you report separately must be above and beyond the E/M service normally provided as a part of the procedure billed, says Barbara J. Cobuzzi, MBA, CPC, CPC-H, CHBME, president of Cash Flow Solutions Inc., a reimbursement consulting firm recently relocated to Brick, N.J.
 
"I recommend that coders do the 'HEM' test - can you pick out from the documentation a clear History, Exam and Medical decision-making? If so, you've got a billable service with a -25," says Laureen Jandroep, OTR, CPC, CCS-P, CPC-H, CCS, director and senior instructor for CRN Institute, an online coding certification training center based in Absecon, N.J.
 
For instance, the emergency department (ED) physician may order nebulizer treatments or review laboratory findings in the ED - however, these are not separately identifiable services, and you shouldn't treat them as such.

Second: Document a Separate E/M

When reporting an E/M service on the same day as another procedure, physically separate the documentation for the E/M. This demonstrates to the payer the E/M service's distinct nature, says Susan Callaway, CPC, CCS-P, an independent coding specialist and educator in North Augusta, S.C.
 
Leave no doubts about the distinct nature of the E/M. The physician should document the history, exam, and medical decision-making in the patient's chart, and record the procedure notes in a way that shows they
are distinct.

Third: Select a (Related or Unrelated) Diagnosis
 
When reporting any E/M service, you must link the service to a diagnosis that explains the reason the physician performed the service. But neither CPT nor CMS requires that the E/M service be "unrelated" to the other service or procedure the physician provides on the same day, Cobuzzi says.
 
CPT specifically states, "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" [emphasis added].
 
Example #1: A patient fell off a bike, experiencing both a head wound that required physician repair and a brief loss of consciousness.
 
Example #2: A patient sprained her ankle ice skating, and the physician both evaluated the injury and treated the ankle with strapping.

Append That -25!

As a last step to guarantee payment for an E/M service on the same day as a procedure or other service, be sure to append modifier -25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) to the appropriate E/M service.
 
Remember: "Modifier -25 is only for E/M services, and documentation must support the significant and sep-arately identifiable nature of the service," Jandroep says