General Surgery Coding Alert

4 steps put you on the path to better reimbursement

Modifier -25 can be your best friend when reporting an E/M service on the same day as a procedure or other service, preventing payers from shortchanging you on valuable reimbursement dollars. But to use the modifier correctly, you must be sure that documentation supports your claim for a separate, significant E/M service.

Don't let this happen to you: A new patient arrives with a complaint of rectal bleeding (569.3, Hemorrhage of rectum and anus). The surgeon provides an E/M service, spending 40 minutes taking the patient's history, performing an exam and deciding to perform a sigmoidoscopy, which does not reveal a more serious problem.

To report the visit, you claim the appropriate test codes (for example, 45330, Sigmoidoscopy, flexible; diagnostic, with or without collection of specimen[s] by brushing or washing [separate procedure]), along with 99243 (Office consultation for a new or established patient ...) for the E/M service. But when the payer returns your claim, you notice that the payer has refused payment for the consult, denying your practice more than $100 for a service properly rendered and documented.

If you want to avoid such an expensive lesson, follow these four steps for billing E/M services with other procedures on the same day.

First: Be Sure the Service Is Significant

To be paid separately, any E/M service you bill at the same time as another procedure must be significant and separately identifiable.

CMS policy dictates that all procedures, from simple injections to common diagnostic tests, include an inherent E/M component. Therefore, any E/M service you report separately must be above and beyond the E/M service normally provided as a part of the procedure billed, says Barbara J. Cobuzzi, MBA, CPC, CPC-H, CHBME, president of Cash Flow Solutions Inc., a reimbursement consulting firm recently relocated to Brick, N.J.

"I recommend that coders do the 'HEM' test -- can you pick out from the documentation a clear History, Exam and Medical decision-making? If so, you've got a billable service with a -25," says Laureen Jandroep, OTR, CPC, CCS-P, CPC-H, CCS, director and senior instructor for CRN Institute, an online coding certification training center based in Absecon, N.J.

Aim for level three or higher, if possible: Although CPT does not provide precise guidelines to define "significant," many coding experts argue that the service should be at level three or higher to qualify as a significant separate service (although there may be circumstances when lower-level codes are appropriate).

For example, if the physician provides a cursory examination because of a new patient complaint during a previously scheduled procedure, the E/M service may not qualify as significant and you should not report it separately.

Second: Document a Separate E/M

When reporting an E/M service on the same day as another procedure, physically separate the documentation for the E/M. This demonstrates to the payer the E/M service's distinct nature, says Susan Callaway, CPC, CCS-P, an independent coding specialist and educator in North Augusta, S.C.

Leave no doubts about the distinct nature of the E/M. The physician should document the history, exam and medical decision-making in the patient's chart and record the procedure notes on a different sheet attached to the chart.

Third: Choose a (Related or Unrelated) Diagnosis
 
When reporting any E/M service, you must link the service to a diagnosis that explains the reason the physician performed the service. But neither CPT nor CMS requires that the E/M service be "unrelated" to the other service or procedure the physician provides on the same day, Cobuzzi says.

CPT specifically states, "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].

Coding example #1: In the above case of the patient with rectal bleeding, the surgeon would link the same signs and symptoms diagnoses (569.3) to the E/M service (99243) that he links to the sigmoidoscopy (45330).

Coding example #2: The surgeon sees a new patient in consultation for a breast mass. She performs a history and exam and decides to perform a needle core biopsy of the breast (19100, Biopsy of breast; needle core [separate procedure]). The biopsy returns negative. In this case, the separate history, exam and MDM determined the need for the biopsy, so you may bill the E/M service separately along with the biopsy. Because the biopsy was negative, you should link ICD-9 code 611.72 (Lump or mass in breast) to both billed CPT codes.

If, however, the surgeon conducts an E/M for a condition unrelated to the diagnosis for which he is delivering the same-day procedure, you should link the separate diagnosis to the E/M.

For instance, if the sigmoidoscopy in the above case had revealed a more serious problem, such as a polyp or tumor, you would use 569.3 for the E/M visit, but you should cross-link the sigmoidoscopy to the appropriate diagnosis code for the polyp or tumor.

Fourth: Append That -25!

As a last step to guarantee payment for an E/M service on the same day as a procedure or other service, be sure to append modifier -25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) to the appropriate E/M service. Returning to our first example above, for instance, you would report 45330 for the sigmoidoscopy and append modifier -25 to the consult code (99243-25).

Remember: "Modifier -25 is only for E/M services, and documentation must support the significant and separately identifiable nature of the service," Jandroep says.