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 [...]