ED Coding and Reimbursement Alert

Answer 3 questions to tell for sure

If you want to recoup reimbursement for your modifier -25 claims, make sure you can separately identify your ED physician's E/M services from other procedures he performs for the same patient on the same day.
 
Here are three easy questions to ask yourself -- with answers from the experts -- to help guide you on the road to hassle-free use of modifier -25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service). 1. Does your E/M service stand alone? CMS specifies that all procedures have an inherent evaluation and management component. Private payers also assume that there's some inherent E/M visit built into the reimbursement for procedure codes, because most physicians do a certain amount of "visiting" with the patient before any procedure. This is why you need to be careful of overuse. Don't append modifier -25 just because your physician spoke with the patient before doing the procedure, says Brenda W. Messick, CPC, a coding specialist in Atlanta.

For Medicare, to properly code using modifier -25, the E/M service needs to be separate and identifiable from the minor procedure, and you need separate documentation for both services. For example, a patient presents to the emergency department following a bicycle accident, and the ED physician does more than just walk into the room and perform a scalp laceration repair. And, the patient has an abrasion on the knee and complains of abdominal pain. The doctor documents an examination, which includes the knee, abdomen and a full neurological exam.

You want to include all the needed E/M documentation, including the plan to repair the laceration. Then you want separate documentation for the repair to show that you have reason to report a complete E/M separately. The repair documentation procedural note can be on the same sheet, or it can be on a separate piece of paper. You can provide the mini-operative report of the repair that tells how the ED physician prepared the patient, what type of anesthetic he used, how many sutures he applied, and other relevant details.

Tip: When asking yourself if a procedure stands alone, separate the E/M notes from the procedure documentation in your medical record. If a reviewer could look at your medical notes and clearly see that the physician completed two separate and independently identifiable services, you can append modifier -25 for Medicare minor procedures.

For CPT payers, reporting works a little differently. CPT only bundles the E/M service performed subsequent to the decision for surgery. So, an E/M may be appropriate if the documentation supports a thorough history and physical exam prior to the decision for surgery.

2. Do [...]