General Surgery Coding Alert

Same-day E/M with identical Dx?  You now have ammunition with payers

A recent CMS memo can give you a leg up on your modifier 25 claims, but it could also signal increased payer scrutiny. What should you do? Follow the guidelines to a -T- and be extra certain to document the significant and separately identifiable nature of the procedure.

Have Evidence of Distinct Service Available

When submitting an E/M claim with modifier 25 (Significant, separately identifiable E/M service by the same physician on the same day of the procedure or other service) on the same day as another service or procedure, the physician must -appropriately and sufficiently- document medical necessity for both the E/M service and the other service or procedure, according to CMS Transmittal 954, issued May 19.
 
Important: CMS now stresses that you don't need to submit this documentation with the claim, but it must be available upon request.
 
Although the transmittal does not constitute a change in policy, you might safely guess that modifier 25 claims -will be under more scrutiny,- says Lisa Center, CPC, coder with Mount Carmel Regional Medical Center in Pittsburg, Kan.

Service Must Be Beyond the Ordinary

If you can't show that the E/M service exceeds the -inherent- E/M component of any other services or procedures performed on the same date, you shouldn't be reporting the E/M service separately -- either with or without modifier 25.
 
Transmittal 954 (Medlearn Matters MM5025, Change Request 5025) adds the word -usual- to the instructions for applying modifier 25. The guidelines now specify that you should apply modifier 25 for -a significant, separately identifiable E/M service that is above and beyond the usual pre- and postoperative work for the service.-
 
The addition is just meant to emphasize that any extra E/M service must be -above and beyond- the typical pre-op or post-op work, says Quinten Buechner, MS, MDiv, ACS-FP/GI/PEDS, CPC, with ProActive Consultants in Cumberland, Wis.
 
Bottom line: If your doctor already plans a procedure and does a pre-op workup, don't bill for a separate E/M. But if the physician doesn't know whether a procedure will be necessary and must rule out other options, you can bill for the E/M, Center says.
 
Example: A new patient comes in with multiple skin lesions, and the physician takes an excisional biopsy of one of them, says Dianne Wilkinson, compliance officer and quality manager with MedSouth Healthcare in Dyersburg, Tenn.
 
The physician collects a history and a review of systems, as well as a family history of malignancy. He examines the patient's lymph, neurological and cardiovascular systems. Then the physician decides which lesions to remove and excises them.
 
If the physician documents everything that happened, you can easily bill for a separate E/M service. But if the physician only documents that he examined and removed some lesions and did an excisional biopsy, you can only bill for the procedures, Wilkinson says.

Separate Diagnoses Aren't Required
 
Transmittal 954 also reminds you (and Medicare carriers) that you don't need a separate diagnosis for the same-day E/M service and other service or procedure.
 
As long as the services are distinct and the separate E/M service is significant, you may, where warranted, link both to an identical diagnosis. This statement closely mimics CPT rules, which state, -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], says Barbara J. Cobuzzi, MBA, CPC, CPC-H, CPC-P, CHBME, president of CRN Healthcare Solutions, a coding and reimbursement consulting firm in Tinton Falls, N.J.
 
Although this is a long-standing CPT rule, CMS payers will still on occasion deny a separate E/M with the same diagnosis, claiming that the E/M is not -distinct.- Now you can show these payers that Medicare guidelines specifically state, -Different diagnoses are not required for reporting the E/M service on the same date as the procedure or other service ...-
 
Example: A new consult patient arrives with a complaint of intense heartburn and abdominal pain. The surgeon takes a complete history and performs an extensive exam. She then performs diagnostic endoscopy to check for reflux disease.
 
In this case, you will report the endoscopy (43200, Esophagoscopy, rigid or flexible; diagnostic, with or without collection of specimen[s] by brushing or washing [separate procedure}). Separate documentation will also support a level-three outpatient consult, to which you should append modifier 25 (99243-25).
 
You should link the signs and symptoms that prompted the exam (787.1, Heartburn; and 789.00, Abdominal pain; unspecified site) to the E/M code. You can link the same signs-and-symptoms diagnoses to the endoscopy. Or if the surgeon finds verifiable evidence of reflux disease (530.xx), you can report that diagnosis as primary with the signs and symptoms as secondary for the E/M service.