Gastroenterology Coding Alert

Separate documentation must stress the distinct nature of the E/M

If you fail to report a legitimate, separately identifiable E/M service, your practice misses out on anywhere from $25 to well over $100. Don't let this happen to you: Here are three ways to be sure that you apply modifier 25 correctly for separate E/M services.

Significance Is Key for Separate E/M

To gain payment for an E/M service the physician provides at the same time as another procedure or service, the E/M must be both significant and separately identifiable.
 
All procedures, from simple injections to common diagnostic tests, include an -inherent- E/M component, according to CMS guidelines. Therefore, any E/M service you report separately must be -above and beyond- the minimal evaluation and management that normally accompanies such a procedure, says Marcella Bucknam, CPC, CCS, CPC-H, CCS-P, HIM program coordinator at Clarkson College in Omaha, Neb.

But modifier 25 is not restricted to a particular level of service, according to CPT Assistant, September 1988.

Example: The gastroenterologist provides a cursory examination prior to a previously scheduled procedure, such as upper GI endoscopy (43235, Upper gastrointestinal endoscopy including esophagus, stomach, and either the duodenum and/or jejunum as appropriate; diagnostic, with or without collection of specimen[s] by brushing or washing [separate procedure]).

In this case, the simple -preprocedure- exam is neither significant nor separately identifiable, and therefore you should not attempt to report it separately.

Tip: -I recommend that coders do the -HEM- test--can you pick out from the documentation a clear history, exam and medical decision-making apart from any other procedures the physician performs on the same day. If so, you-ve probably got a billable service- with modifier 25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service), says Laureen Jandroep, OTR, CPC, CCS-P, CPC-H, CCS, director and senior instructor for CRN Institute, an online coding certification training center based in Absecon, N.J.

Bottom line: You should consider a brief history and physical prior to a same-day scheduled outpatient procedure as an included component of the procedure itself.

Even if the physician provides an assessment and plan, you probably should not report a separate E/M service unless the patient has a new, unrelated complaint or has experienced a worsening of symptoms that prompts a new history, exam and medical decision-making process that might include additional testing or therapy.

Keep E/M Documentation Apart

 When reporting an E/M service on the same day as another procedure, physically separate the documentation for the E/M portion of the service from the procedure documentation. This demonstrates to the payer the E/M service's distinct nature, Jandroep says.

The physician should document the history, exam and medical decision-making in the patient's chart and record the procedure notes on a different sheet attached to the chart.

The AMA weighs in: Revised explanatory text for modifier 25 in CPT 2006 specifically stresses the importance of documentation and instructs coders that a -significant, separately identifiable E/M service is defined or substantiated by documentation that satisfies the relevant criteria for the respective E/M service- you choose to report.

Select a (Related or Unrelated) Dx

For any E/M service, you must link the service to a diagnosis that explains the reason the physician performed the service. But the E/M service needn't necessarily be -unrelated- to the other service or procedure the physician provides on the same day, Bucknam says.

CPT specifically states, -The E/M service may be prompted by the symptom or condition for which the procedure and/or service was provided. As such, different diagnoses are not required for reporting of the E/M services on the same date- [emphasis added].

Example: A patient arrives for a consult because of abdominal pain and bloody diarrhea. The physician assigns primary signs-and-symptoms diagnoses of 789.0x (Abdominal pain) and 787.91 (Diarrhea NOS), which she links to the consult (for example, 99243, Office consultation for a new or established patient ...). The gastro also performs a flexible sigmoidoscopy (45331, Sigmoidoscopy, flexible; with biopsy, single or multiple).

Because the abdominal pain and diarrhea prompted the flexible sigmoidoscopy, you may use the same diagnoses (789.0x and 787.91) to support the diagnostic procedure and the E/M service.

In this case, report 45331 for the sigmoidoscopy and add modifier 25 to the consult code (99243-25) to show that the E/M service was significant and separate from the diagnostic scope.