General Surgery Coding Alert

In a memorandum released Feb. 8, 2001, (B-01-09, Change Request 1546) HCFA announced the suspension of edits that bundled 66 evaluation and management (E/M) codes with more than 800 diagnostic tests and other services listed in the Medicare fee schedule as having XXX global days. The edits were originally introduced in version 6.3 of the national Correct Coding Initiative (CCI).

When HCFA first announced its intention to bundle E/M services with diagnostic tests in the November 1999 Federal Register, the agency stipulated that significant and separately identifiable E/M services would be payable if modifier -25 (significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) was attached to the E/M code.

Since the edits were implemented on Oct. 30, 2000, physicians, including general surgeons, have reported an increase in denials for E/M services performed on the same day as diagnostic tests, such as mammograms, ultrasounds, most radiological services, and vascular studies, such as 93925 (duplex scan of lower extremity arteries or arterial bypass grafts; complete bilateral study) and 93926 (... unilateral or limited study). HCFA now says that before reintroducing the edits it will strengthen efforts to educate physicians and its own carriers about the appropriate use of modifier -25 and what constitutes a significant, separately identifiable E/M service.

Append Modifier -25 as Necessary

HCFA initially argued the edits were designed to prevent the practice of physicians reporting an E/M service code for the inherent evaluative component of the procedure itself. As a basis for the policy, the agency reasoned, Because every procedure has an inherent E/M component, for an E/M service to be paid separately, a significant, separately identifiable service would need to be documented in the medical record.

HCFA now says that any claims involving E/M services and diagnostic tests after Oct. 30 should be resubmitted, and recommends attaching modifier -25 to the E/M service when refiling. In other words, general surgeons are still required to demonstrate that the E/M service was significant and separately identifiable.

Recognizing Separately Identifiable E/M Services

E/M services are separately payable if the documentation indicates that the visit led to the decision to perform a procedure, for example a diagnostic test such as a duplex scan.

If the surgeon performs a full E/M workup, including history, examination and medical decision-making on an established patient, and subsequently orders a breast ultrasound (76645), the appropriate E/M (9921x) can be billed in addition to the ultrasound with modifier -25 attached, says Arlene Morrow, CPC, an independent general surgery coding and reimbursement specialist in Tampa, Fla. The E/M service is significant and separately identifiable, and therefore may be separately billed. But documentation must clearly convey the development of the encounter toward the taking of the test, Morrow explains. She notes that the information must be substantive enough to demonstrate medical necessity for the encounter and avoid suspicion of double billing.

Meet Diagnosis Requirements

According to CPT and HCFA guidelines, separate diagnoses for the E/M service and the test are not required, but if two or more diagnoses are available, each should be linked to the appropriate service.

For instance, if a patient complains of right lower quadrant pain, the surgeon may order a test for elevated white blood count (WBC) to rule out appendicitis and perform an ultrasound to rule out an ovarian mass. If the ultrasound is positive, ICD-9 code 793.6 (nonspecific abnormal findings on radiological and other examination of body structure; abdominal area, including retroperitoneum) should be linked to the ultrasound. The pain diagnosis should be associated with the E/M service. If the tests are negative, the pain diagnosis still provides medical necessity for both the E/M and the tests, but the claim should include a comment explaining why the tests were performed and documentation that indicates the E/M service led to the decision to perform the test (or vice versa, if the tests led to the surgeons decision to examine the patient).

Defining Significant Services

To prove an E/M service is separately payable, it should exceed a level-two encounter, Morrow explains. Significance relates to the purpose of the patient encounter, including the context of the visit [i.e., the chief complaint] and the medical decision-making involved, she says. All the components that are taken into account when determining the level of the visit time, effort, complexity and treatment options must be documented to indicate that the visit was significant.

This requirement is of particular importance for E/M services provided at the same time as a diagnostic test because the pretest evaluation built into the tests relative value is typically not substantial. Documentation indicating a significant service was provided offers additional evidence that double-dipping has not occurred.

HCFA Will Monitor Modifier -25 Claims

Some physicians have reported receiving warnings from carrier representatives about attaching modifier -25 to E/M services performed with diagnostic tests, even though the use of the modifier in such circumstances was mandated by HCFA thus emphasizing the importance of accurate documentation in the event of an audit.

Physicians and their specialty societies also report receiving erroneous information from carriers, including:

Automatic denials for E/M services performed on the same day as diagnostic tests;
Being told to attach modifier -59 (distinct procedural service) to the E/M service; and
Being told that two diagnoses are required for both services to be paid.

HCFA has pledged to work with the AMA and specialty medical societies to continue educational efforts on correctly appending modifier -25 to E/M services when billed with diagnostic tests and other services with XXX global days performed on the same day.

HCFA claims it will develop a program to guide and educate carriers, and will direct the carriers to publish clear and accurate information about the edits in local Medicare bulletins. Finally, the agency says it will attempt to ensure its carriers implement existing national policy that allows the same ICD-9 code to be associated with both the E/M service and whatever service or procedure has been provided on the same day.

Until then, coders should talk to a government policy representative with their local Medicare carrier who can answer questions about medical and surgical coding and billing practices.