EM Coding Alert

Question: Our surgeon saw a patient in the office who was referred by another physician for placing a drug-delivery implant. The surgeon performed a brief patient evaluation and exam before performing the procedure. I billed this with modifier 25 and the claim was rejected - could you explain why?

Illinois Subscriber

Answer: You don't state what codes you used, so it's hard to know for sure the reason for the denial.

However, assuming that you billed the evaluation and management (E/M) services with a code such as 99201 (Office or other outpatient visit for the evaluation and management of a new patient, which requires these 3 key components: A problem focused history; A problem focused examination; Straightforward medical decision making ...) and the implant service with 11981 (Insertion, non-biodegradable drug delivery implant), the problem may be with the modifier.

You should append 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 the E/M code only when you meet certain conditions, as follows:

• The E/M occurs on the same day as the surgical procedure
• The procedure following the E/M is minor (has a zero or 10-day global period)
• The E/M service is both significant and separately identifiable from any inherent E/M component, and that the procedure involves the same physician (or one with the same tax ID) who provides the E/M service.

Let's assume that you have documentation that your surgeon performed a separately identifiable E/M service. But the procedure code for the drug-delivery implant (11981) does not have a global period of 0 or 10 days. Instead, CMS assigns a global code of XXX, which means that the global concept does not apply. In other words, no E/M service is built into the reimbursement for 11981.

Do this:  You can bill the E/M, such as 99201, and the procedure code 11981 together without using modifier 25 or any other modifier.

Problem: Even if this case hadn't resulted in a denial (because you were billing the appropriate codes), common misuse of a modifier such as 25 can open your practice up to payer scrutiny. Make sure you understand the rules for modifier use and apply them appropriately.