ED Coding and Reimbursement Alert

The physician always performs some type of E/M preprocedure, and not all are separately reportable

While it is important for coders in all specialties to know the rules for reporting separate evaluation and management services along with procedures on the same claim, knowing these rules may be even more important for ED coders.

When your ED physician performs an E/M service and then a procedure, and you can prove they are significant and separate, you can report the E/M using modifier 25 (Significant, separately identifiable E/M service by the same physician on the same day of the procedure or other service).

If you have trouble deciding whether you have a modifier 25-eligible claim, follow this advice to see if you can report the E/M separately.

Find Evidence of Separate E/M in Notes

The most vital element on successful modifier 25 claims is concrete evidence that the procedure and E/M were truly separate, says Catherine Brink, CMM, CPC, president of Healthcare Resource Management of Spring Lake, N.J. All procedure codes have an inherent E/M component built into them, and the physician must go beyond that to justify a separate E/M.

For example, a Medicare patient presents with a simple finger laceration. The physician examines the finger and places two sutures. The physician's documentation is limited to an exam of the finger and scant history related to how the laceration occurred.

In Medicare's eyes, you have likely not met the requirements for a significant, separately identifiable E/M service; just report the procedure code on this claim.

Now check out this detailed scenario from Brink, in which the ED physician performs both procedures and a significant and separate E/M service:

A patient presents to ED via ambulance from a motorcycle accident. The bike hit a pothole, and the patient lost control, falling off the cycle and hitting his arms on the pavement. Both lacerations are contaminated with particulate matter, and the patient says his head and neck hurt.

The review of systems (ROS) reveals that the patient wears glasses and one hearing aid. He also has coronary artery disease (CAD) and takes 20 mg of Lipitor daily. All other systems were within normal limits (WNL). The patient has had no previous surgeries.

The exam reveals that the patient's head and face contain no contusions or lacerations. The patient has neck pain and restricted range of motion. Both of the forearm lacerations need extensive debridement to determine the extent of the injuries.

The physician conducts an 8-cm laceration single- layer repair on the right forearm with extensive debridement due to particulate matter and thus intermediate wound closure. He then performs a 6-cm laceration closure of the same complexity to the left forearm. After taking x-rays of the patient's neck, the physician orders two Percocet for the patient's pain.
 
This scenario contains a procedure code and a separate E/M. On the claim, you should:

- report 12035  (Layer closure of wounds of scalp, axillae, trunk and/or extremities [excluding hands and feet]; 12.6 cm to 20.0 cm) for the right and left forearm repairs. Remember to sum the lengths of repairs of the same classification and anatomical area.

- report an E/M service, probably 99284 (Emergency department visit for the evaluation and management of a patient, which requires these three key components: a detailed history; a detailed examination; and medical decision-making of  moderate complexity).

- append modifier 25 to 99284 to show that the E/M was separate from the wound repairs.

- report 959.09 (Injury of face and neck) with 99284 to prove medical necessity for the E/M service.

- report E816.2 (Motor vehicle traffic accident due to loss of control, without collision on the highway; motorcyclist) with every one of the CPT codes on the claim to show the payer how the patient was injured.

Don't Bury the Procedure Note

On the above claim, you should make sure the notes for the E/M and the procedure stand separately, says Cindy Parman, CPC, CPC-H, RCC, co-owner of Coding Strategies Inc. in Powder Springs, Ga. -Generally, we advise physicians not to bury the procedure in the patient visit note. It helps to have a separate paragraph from the E/M that states -procedure note- and includes a brief description of the procedures,- she says.

Check out what CPT Assistant 2004 has to say about modifier 25 claims: -Generally, separate documentation of each service (e.g., E/M and procedure) is recommended so that each service is readily and individually identifiable as such. Each may be documented separately in progress or other appropriate notes. Separate pages for each service are not required.-

Separate Dx Not Necessary for Modifier 25 Claims

Although the patient in the motorcycle-accident scenario had a complex presentation, the patient does not need separate diagnoses for each service. Sometimes, the patient will need a procedure and a separate E/M for the same complaints.
 
Example: A 60-year-old male presents with chest pain. The physician performs an E/M service as well as an EKG. In this case, the chest pain diagnosis (786.50, Chest pain, unspecified) supports both the E/M service and the diagnostic testing.