The answer to your question gives 'yes' or 'no' to modifier 25. If your internist performs an E/M service and a procedure on the same patient during the same encounter, you might be able to report the E/M using modifier 25 (Significant, separately identifiable E/M service by the same physician on the same day of the procedure or other service). Or you might not. The key:
Uncover E/M Evidence in Notes
"Coders should use modifier 25 when a significant, separately identifiable E/M service is performed by the same physician at the same face-to-face encounter as a procedure or other service," says Catherine Brink, CMM, CPC, president of Healthcare Resource Management of Spring Lake, N.J.
The most vital element on successful modifier 25 claims is concrete evidence that the procedure and E/M service were truly separate, Brink says. All procedure codes have an inherent E/M component built into them, and the physician must go beyond that to justify a separate E/M. In addition, the E/M service must also meet medical necessity criteria. If it doesn't, you should just report the procedure code.
Watch for Exam That's Beyond 'Limited'
Now check out this scenario in which the physician performs a procedure and a separate E/M service: A new patient presents with dull aching pain in his jaw. The pain has persisted for three weeks, and despite taking Motrin for the pain, he's gotten no relief. The patient is a teacher, and he says the pain gets worse after he teaches classes all day.
Your internist performs a review of systems; past, family and social history; an expanded problem-focused history and an expanded problem-focused exam on the jaw, including a check for tenderness, swelling, popping/clicking or difficulty moving. He makes an initial diagnosis of temporomandibular joint disorder but orders follow-up tests as confirmation. In the meantime, he administers a trigger point injection to relieve the patient's immediate pain.
Code it:
In this instance, the internal physician performed a significant E/M service before deciding to administer the injection. On the claim, therefore, you should report the following: