ED Coding and Reimbursement Alert

CMS says procedure, E/M can still share Dx

When an ED physician treats a patient and provides a significant, separately identifiable evaluation and management service, you can report the E/M separately from the other service with modifier 25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service. )
 
But you-ll need to be even more vigilant about proving the separate E/M now, because a recent federal directive indicates a crackdown on modifier 25 claims.
 
The lowdown: Documentation for claims using modifier 25 may be under heavier scrutiny soon, judging from the May 19 release of Transmittal 954 by the Centers for Medicare and Medicaid Services.
 
In this transmittal, CMS:
 - adds the word -usual,- so the guidelines now read: -a significant, separately identifiable E/M service that is above and beyond the usual pre- and postoperative  work for the service.- The addition is just meant to emphasize that any extra E/M service must be -above and beyond- the typical pre-op or post-op work, says Quinten Buechner with ProActive Consultants in Cumberland, Wisc.
 - clarifies that you don't need a different diagnosis for the E/M service and the procedure or other service.
 - stresses you must make sure that you have appropriate documentation proving the medical necessity of the separate same-day E/M service. You don't need to submit this documentation with the claim, but it must be available upon request.

It's safe to say that modifier 25 claims -will be under more scrutiny,- though none of these changes are major, says Lisa Center, coder with Mount Carmel Regional Medical Center in Pittsburg, Kan.
 
Bottom line: If your doctor already plans a procedure and does a pre-op workup, don't bill for a separate E/M. But if the physician doesn't know whether an operation will be necessary and must rule out other options, you can bill for the E/M in which the doctor reaches the decision for surgery, Center says.