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 [...]