General Surgery Coding Alert

Question: May we report a diagnostic endoscopy and E/M service on the same day? The payer keeps rejecting our claims.

Arizona Subscriber

Answer: Yes, you may report both a diagnostic endoscopy and an E/M service on the same day, but only if you 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 E/M service, which must be demonstrably significant and separately identifiable from the "inherent" E/M service included in the scope.

CMS policy dictates that all procedures, from simple injections to common diagnostic tests, include an inherent E/M component. Therefore, to be paid separately, any additional E/M service must be significant and separately identifiable (that is, above and beyond the E/M service normally provided as a part of the procedure billed). And, you must specifically document the separate E/M service in the medical record.

In the absence of specific CMS guidelines, many coding experts have determined that an E/M service should qualify as at least a level-three encounter to be "significant." You must document all the components taken into account when determining the level of the visit including time, effort, complexity and treatment options to verify that the visit was indeed significant.

For example, if the physician provides a cursory examination because of a new patient complaint during a previously scheduled procedure, but the exam by itself does not exceed a level-one or -two E/M service (for example, 99211 or 99212), the service is not significant enough to be separately reported or reimbursed. One or two questions directed to the patient do not qualify as a significant E/M service.

If a new complaint necessitates a higher-level E/M, such as 99214 (Office or other outpatient visit for the evaluation and management of an established patient ...), the service is significant enough to qualify for separate reimbursement.

In most cases, modifier -25 is not appropriate for a previously scheduled procedure. Physicians will often perform a quick patient review on the same day as a scheduled procedure, but most will not include an exam or medical history. In these cases, you cannot bill a separate E/M service because the brief encounter is part of the procedure. A limited exam is integral to the procedure and therefore neither significant nor separately reportable.

Significance is particularly important for E/M services provided at the same time as a diagnostic test (such as a diagnostic scope) because the pretest evaluation included in the test's relative value is generally not very substantial. Documentation indicating that the physician provided a significant service demonstrates that you are not trying to "double-dip."

An effective method to stress the separately identifiable nature of an E/M service is to physically separate the E/M notes from the procedure notes in the medical record. 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. In this way, you clearly identify the two services and individually support them by documentation.