EM Coding Alert

Question: We have a provider in our practice who insists on adding an office/outpatient evaluation and management (E/M) code for every patient who already has an established plan of care. The provider states that the patient’s care plan changes at every encounter, and even if they are coming in for care they have had for years, the situation is always changing.

However, when I look at the documentation, I see nothing has changed since the last encounter, and no new problems are being addressed to justify the E/M. How do I communicate effectively to the provider that only the procedure can be billed in these circumstances?

AAPC Forum Participant

Answer: To legitimately bill an established patient E/M using 99211-99215 (Office or other outpatient visit for the evaluation and management of an established patient …) along with any procedure, you must have supporting documentation and append a modifier such as 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. As the descriptor language indicates, the E/M service must be significant and separately identifiable from the procedure or other service performed on the same date.

In some specialties, patients are often seen for ongoing care of an existing complaint. In some cases, an E/M code is appropriate for the care provided. If the care service has a distinct, non-E/M CPT^® code, any minor evaluation and management of an existing condition possibly would be covered as a part of that service. To help understand when using modifier 25 is appropriate, your payer may have a fact sheet. The National Correct Coding Initiative Policy Manual for Medicare Services also has helpful information, such as this quote from Chapter XI, Section U.6:

“With most ‘XXX’ procedures, the provider may, however, perform a significant and separately identifiable E/M service that is above and beyond the usual pre- and post-operative work of the procedure on the same date of service which may be reported by appending modifier 25 to the E/M code. This E/M service may be related to the same diagnosis necessitating performance of the ‘XXX’ procedure but cannot include any work inherent in the ‘XXX’ procedure, supervision of others performing the ‘XXX’ procedure, or time for interpreting the result of the “XXX” procedure. Examples of ‘XXX’ procedures include allergy testing and immunotherapy, physical therapy services, and neurologic and vascular diagnostic testing procedures.”

You also should review the Medicare Claims Processing Manual, Chapter 12, Section 30.6.6, which provides similar information.