General Surgery Coding Alert

Some general surgeons and coders are uncertain about whether and when to bill a visit on the same day as a procedure, for example, when the procedure and visit both relate to the same problem. In practice, this often means that two different diagnosis codes should be used and that a single diagnosis code is appropriate only if the diagnosis is a sign or symptom that is not repaired or identified by the ensuing procedure.

The underlying issue, however, should not be the second diagnosis. The number of diagnoses is not the determining factor, says Kathy Pride, CPC, CCS-P, a coding and reimbursement specialist with Martin Memorial Medical Group in Stuart, Fla. Its whether you can prove the procedure wasnt planned or scheduled. If two diagnoses arent available, the surgeons notes should support the fact that only after the visit did the need for the procedure arise, Pride says.

Billing Criteria for Visits

Two factors determine if the visit may be charged: (1) Did the visit lead to the procedure being performed? and (2) Was the visit significant?

If the procedure is preplanned and the visit is just a routine check, no evaluation and management (E/M) service should be charged. But if the history, examination and medical decision-making were significant and directly led to the decision to perform the procedure, it should be payable.

For example, a primary-care physician (PCP) requests a consult for an 86-year-old patient with a cystic thyroid mass. The surgeon reviews the PCPs workup and data, assesses the patients suitability for surgery and decides to aspirate the cyst the same day.

Because the visit was significant and directly led to the decision to perform the procedure, it should be payable, but only if the documentation clearly indicates the link between the visit and the decision to aspirate the cyst. The documentation has to indicate that the surgeon did not know the procedure necessarily would be performed, Pride says. It all depends on what the surgeon intended to do when the patient arrived.

In this instance, a second diagnosis is sufficient documentation to indicate to the carrier that the physician examined the patient before determining a course of action. The consult, therefore, would be coded 9924x-25 (the appropriate consult code with modifier -25 [significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service] attached), and would be linked to ICD-9 code 784.2 (lump in neck). The aspiration of the cyst is coded 60001 (aspiration and/or injection, thyroid cyst) with ICD-9 code 246.2 (cyst).

The number of diagnoses used is not the issue; rather, it is what they reveal about the patient encounter. Clearly, if the physician had written down patient here for aspiration of thyroid cyst, no E/M visit could be charged because the procedure is documented as pre-planned. Similarly, if the physician uses code 246.2 both for the visit and the procedure, it likely will be denied because it signals to the payer that the surgeon already knew what the problem was and had decided on a particular course of action (aspiration of thyroid cyst), Pride says.

In short, although the Health Care Financing Administration (HCFA) no longer requires two diagnosis codes for an E/M office visit to be paid the same day as a procedure, appropriately using two diagnosis codes can be a helpful way to indicate to the carrier the medical necessity of both services.

Even if a visit leads to a service, the visit still may not be separately payable if it is not significant, says Barbara Cobuzzi, MBA, CPC, CPC-H, an independent coding and reimbursement specialist in Lakewood, N.J. For example, a patient comes in with a mole that seems to have changed color and shape, which the surgeon examines and then removes. Even though the examination led to the surgeons decision to remove the mole, the exam likely was not significant enough to warrant separate payment over and above the lesion removal, Cobuzzi says.

There will be times, even with a new patient, that you cant justify an E/M visit the same day as a procedure, such as when a lesion is removed, because the effort for exam and evaluation of the condition is so minimal it cant be significantly broken out from the service, she says.

On the other hand, if a new patient presents with an unusual mole and the surgeon takes the patients history, is uncomfortable with the look of the mole and performs an exam, makes the medical decision to excise it after considering other alternatives (i.e., biopsy, frozen section), and all this is documented in the surgeons notes, then billing for the visit would be justified.

Billing Medicare With Only One Diagnosis

Medicare will pay for visits performed the same day as a procedure even if there is only one diagnosis, if the visit is significant and determines the need for the procedure. For example, a patient presents with rectal bleeding (569.3, hemorrhage of rectum or anus). Based on this symptom, the surgeon examines the patient and then decides to perform a sigmoidoscopy (45330, sigmoidoscopy, flexible; diagnostic, with or without collection of specimen[s] by brushing or washing [separate procedure]), which does not reveal a more serious problem.

In this instance, the rectal bleeding diagnosis should be cross-linked both to the visit and the sigmoidoscopy.

Assuming the documentation indicates that the surgeon made the decision for the sigmoidoscopy after examining the patient, both services should be billable.

Had the sigmoidoscopy revealed a more serious problem (such as a polyp or tumor), code 569.3 would be used for the visit, but the sigmoidoscopy would need to be cross-linked to the appropriate diagnosis code for the polyp or tumor.

Another example would be a new patient seen in consultation for a breast mass. The surgeon does a history and exam and makes the medical decision to perform a needle core biopsy of the breast (19100, biopsy of breast; needle core [separate procedure]), which returns negative. Because there is a separate history, exam and decision-making process that determines the need for the biopsy, the E/M, in this case a new patient visit (9920x), would be billable with modifier -25, along with the biopsy itself, as long as the documentation in the patients chart supports the claim. Because the biopsy was negative, ICD-9 code 611.72 (lump or mass in breast) would be linked both to the biopsy and the new patient visit.

Note: For the E/M to qualify as significant, the complexity level of the visit must be more than straightforward, i.e., the medical decision-making should be at least of low complexity.

Commercial Carriers Demand Second Diagnosis

Although Medicare carriers routinely pay for E/M services with modifier -25 attached and, in most states, do not require a second diagnosis for such claims, some third-party payers refuse to recognize the modifier altogether or, alternatively, demand a second diagnosis, Cobuzzi says.
The requirement for a second diagnosis is a misinterpretation of the intent of the modifier and should be appealed, although she notes that the chances of successfully overturning such denials are not great.

To minimize reimbursement denials for this reason, appeals should quote section 15501.1 of the Medicare Carriers Manual, which defines the correct use of modifier -25. If the physician launching the appeal understands the issues involved, the appeal likely will be taken more seriously.

Note: In 1999, CPT issued a clarification stating that a physician may use modifier -25 to bill a visit using the same diagnosis that was used for the procedure. Previous CPT books did not explicitly say two separate ICD-9 codes had to be used, but were more vague.