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 [...]