Gastroenterology Coding Alert

Question: My provider performed a procedure and performed an evaluation and management (E/M) service, so does that mean I just need to append modifier 59 to separate it from the E/M? If so, to which code do I append the modifier?

California Subscriber

Answer: The CPT^® description for modifier 59 (Distinct procedural service) says it “should not be appended to an E/M service. To report a separate and distinct E/M service with a non-E/M service performed on the same date, see modifier 25).” 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) is the more appropriate modifier to use in this situation. However, the documentation is what will dictate whether you can submit an E/M at all. Here’s why.

Payers require that the documentation adequately describe not just a history and physical examination (H&P), but also all the work the provider did to manage whatever problem the patient presented with. If the patient had a procedure done in the office, then told the provider of recent pain in another part of the body, for example, the notes would have to detail the provider’s discussion, evaluation, and all thoughts on what the new problem may or may not be, including the plan for managing the problem going forward.

There are only a few situations that justify an E/M with a procedure in the first place: the patient is new (and the documentation clearly supports evaluation as well as management of a problem), the established patient has a new problem unrelated to the procedure, the established patient has new information or concerns about the problem associated with the procedure, or the old or new patient brings up a new problem. In all these situations, there needs to be a clear record of the E/M portion of the visit that separates it from the procedure. For more details, check out Chapter 1 of the NCCI policy manual for Medicare Services (https://www.cms.gov/sites/default/ files/2021-12/Chapter1_2022_CMP_Final_1.1.2022.pdf).