EM Coding Alert

Question: We had a patient present to the office for a relatively minor problem. Our doctor provided an E/M service and sent the patient home. Later, the same patient suddenly developed terrible pain. He contacted the same doctor who had him go to the hospital for an emergency procedure.

The E/M deserves separate reimbursement, but I’m not sure which modifier to use. Modifier 57 is a decision for surgery and there was no decision for surgery during the initial office encounter. I want to use modifier 25 as the E/M was a separately identifiable service on the same day as a procedure, but the procedure puts the patient into a 90-day global period. I can’t use modifier 22 as it’s not supposed to be used with an E/M service. How should I bill for this?

New York Subscriber

Answer: You should report the appropriate E/M service code, such as an established patient office visit code (99211-99215, Office or other outpatient visit for the evaluation and management of an established patient, …), with modifier 57 (Decision for surgery) attached. Then, report the appropriate surgical code for the procedure performed in the ER.  However, you will want to check with your payers as some may want that visit bundled into the surgery service. 

Watch out: The emergency department codes (99281-99285) would not be appropriate as that was where the physician told the patient to meet her. When a provider asks a patient to “meet” in the ER, this does not qualify as an emergency visit that can be coded with those service codes.

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) would not be appropriate as it is used on an E/M services the same day as a minor procedure. Modifier 22 (Increased procedural services), as you indicated, is not used on E/M services. Thus, modifier 57 is the only choice in this scenario. 

The physician’s documentation may also help with this. Usually, the physician will write what was told to the patient should the symptoms worsen. She may have indicated if the problem does not improve, surgery may be necessary. This will help confirm that modifier 57 is the correct choice.