EM Coding Alert

These two cases will help keep your 2021 E/M-25 decisions straight.

Much of the discussion among coders regarding next year’s changes to the office or outpatient E/M code changes has, quite logically, been about the way code choices will be made in 2021. So, the fact that you will be choosing your office or outpatient E/M levels based on medical decision making (MDM) or time should be old news by now.

What might not be so obvious, though, is the way you will be reporting a separate office or outpatient E/M on the same day as a minor procedure using modifier 25 (Significant, Separately Identifiable Evaluation and Management Service by the Same Physician or Other Qualified Health Care Professional on the Same Day of the Procedure or Other Service) to unbundle the services.

Fortunately, Lori A. Cox, MBA, CPC, CPMA, CPC-I, CEMC, CGSC, CHONC, walked through two scenarios to help you keep your modifier 25 decisions on the level beginning on January 1 in her recent presentation “E/M Guidelines 2021 — Office Visits With Minor Procedures,” at HEALTHCON 2020 Regional Virtual Conference.

Remember Built-In Surgical E/M Component

Cox began by reminding coders that you will still need to prove a separate E/M before reporting it with modifier 25. “All procedures have a component of E/M in them: decision for surgery, pre-and postop work. Also, 90 percent of the minor procedures in CPT^® already have a component of E/M built into that procedure. So, modifier 25 use has to be backed with a good case for a separate E/M,” she continued.

Cox also reminded coders that one important rule will not be changing in 2021. You will still not use modifier 25 when there is an E/M with a same-day procedure with a major (90-day) global when the decision is made 24 hours prior to surgery. That is for modifier 57 (Decision for surgery). For the purposes of this article, all of the procedures will have a minor (0- or 10-day) global.

Cox then ran through two examples of when — and when not — to report a separate E/M-25 based on 2021 E/M rules.

Case 1: MDM-Based 99214 With Modifier 25

Patient presents with worsening knee pain. The physician evaluates the entire musculoskeletal system and believes the patient may have a more significant issue such as rheumatoid arthritis (RA). For today, the physician will do a knee injection for relief. They schedule the patient for an additional work-up to test for RA, including four lab tests and several X-rays.

“Patient has an undiagnosed new problem, so the provider does additional workup for possible RA,” said Cox. This is a sign that you should look for a separate E/M. Though finding that E/M is not guaranteed, in this case there is a separately identifiable problem that caused the provider to go above and beyond the operative package E/M, which is vital.

This also meets the criteria for 99214 (Office or other outpatient visit for the evaluation and management of an established patient, which requires a medically appropriate history and/or examination and moderate level of medical decision making …) in 2021 based on MDM: An undiagnosed new problem with uncertain prognosis (Moderate) and tests ordered related to the new problem (Moderate).

In addition to the operative notes, Cox explained that the documentation in these cases could be aided by statements relevant to the encounter, such as: “I spent 12 minutes performing a knee injection, then spent 20 minutes discussing rheumatoid arthritis management with patient.”

Case 2: No Separate MDM-Based 99214 With Modifier 25

Here’s an example where the question of a separate 99214-25 becomes murkier: An HIV-positive patient with known osteoarthritis presents with a flare-up in her left ankle. Injections have helped in the past. The provider orders an X-ray to be completed in his office today. The X-ray shows no acute processes. The provider performs an injection and instructs the patient to return if there is no relief in three days.

Though this might meet the MDM-based definition of 99214 in 2021, there isn’t conclusive proof that the provider went above and beyond the normal operative package E/M to treat a separately identifiable problem.

“The doctor never tells us much about the HIV, so I cannot count that. The doctor is not making clear to me whether or not he does anything different due to the HIV. He probably does, but we need to know,” Cox said. “So, I don’t think that you can report an E/M-25 along with the procedure code. You might make the case that he’s ordering an X-ray, but we’re already billing for that and the injection. So, where is the separate E/M? I’m the kind of person where if I don’t know something, I don’t count it [toward E/M].”

“This is very difficult, and I can see some ways to justify coding an E/M if he ordered an X-ray, but he might do that all the time; I just don’t know” if this note proves a significantly separate E/M service, Cox said.