EM Coding Alert

Question:  Can I bill Medicare for an office visit and cystoscopy on the same day using a modifier 25?

California Subscriber

Answer: Yes, you can bill a cystoscopy (52000, Cystourethroscopy [separate procedure]) and an office visit such as 99213 (Office or other outpatient visit for the evaluation and management of an established patient ...) on the same day as long as the physician’s documentation supports the significant, separately identifiable E/M service.

Append modifier 25 (Significant, separately identifiable evaluation and management service by the same physician or other qualified healthcare professional on the same day of the procedure or other service) to 99213 to indicate that your physician performed a separate E/M service.

Example: A patient comes to your office for a routine follow-up cystoscopy, and after the procedure the physician reviews the results of the examination with the patient indicating that he found a recurrent bladder tumor. The physician counsels the patient and coordinates his care, discussing transurethral resection of bladder tumor (TURB) and necessary further work up. For this scenario, you should bill for the cystoscopy and also for an E/M service with modifier 25. Select the E/M level based on the amount of time the physician spent counseling the patient and coordinating his care.

Example 2: Following a scheduled negative cystoscopic examination, a patient brings up and discusses another problem with the physician, such as worsening impotence. The physician performs an examination, discusses this new problem with the patient, and recommends therapy.

This is a new problem, and the physician should document this in the medical record as a separate and new diagnosis. In this case, you should bill 52000 and also an office visit code separately with modifier 25 attached because different diagnoses will support separate services. If that same patient had had only the cystoscopic examination and no separate E/M service, then you would not bill a separate office visit code.

Bottom line: The documentation and medical necessity must demonstrate that the E/M was a significantly, separately identifiable service.