You Be the Coder:
Two-Provider E/M
Published on Fri Mar 01, 2002
Test your coding knowledge. Determine how you would code this situation before looking at the box below for the answer.
Question: Prior to performing a procedure on a patient, we will see him or her in our office for an E/M service and then later that same day we will perform the procedure at our ambulatory surgical center (ASC). We usually add modifier -25 (Significant, separately identifiable E/M service by the same physician on the same day of the procedure or other service) to the E/M code but what if two people see the patient? If a physician assistant handles the E/M service, and the gastroenterologist does the procedure, should we add modifier -25? What if physician A performs the E/M service, gets an emergency call and has physician B perform the procedure?
Texas Subscriber
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Answer: The question of whether to use modifier -25 is secondary to this issue because it sounds as if the E/M you described is really a standard preoperative history and physical (H&P), which is bundled into the procedure and is not separately reportable, says Mary Falbo, MBA, CPC, president of Millennium Healthcare Consulting Inc. in Lansdale, Pa.
Preoperative visits after the decision to perform a procedure has been made are considered part of the global surgical package and are not separately billable, according to the Medicare Carriers Manual sections 4821(A) and (C). These services may be furnished in any setting, including the gastroenterologists office, ASC or hospital, so it makes no difference that the E/M and the procedure are performed in two separate places.
A same-day E/M service is only billable when the service performed is significant and separate from the procedure performed. It would be billable if the patient is being seen for a separate condition, one that is different from the condition being addressed by the procedure. Because your patients are already scheduled for an appointment at the ASC when they come to the office for the E/M, it seems unlikely that they would regularly have appointments to discuss other conditions on the same day as a procedure.
If the E/M services are significant and separately billable, the situations you described may require you to add modifier -25 even though the CPT definition of the modifier is for an E/M service by the SAME physician on the SAME day as the procedure or other service. With the two scenarios you cited, it may appear to the payer that one person is performing both the E/M and the procedure even though there are two.
If the physician assistant performs a separate and significant E/M, you would add modifier -25 because the physician assistant is an employee of the practice and will be billing under the practices tax identification number.
In your second situation where another physician performs the procedure instead of your gastroenterologist, both physicians are probably from the same practice because they are using the same ASC. If that is the case, you should attach modifier -25 to the E/M code because both physicians will be filing under the practices tax identification number and the payer will probably view them as the same physician. | |
