Medicare Compliance & Reimbursement

Question: In the introduction to Correct Coding Initiative (CCI ) version 13.3 and the subsequent versions (including the most recent, 14.1), it says, "... a significant and separately identifiable E/M service unrelated to the decision to perform the minor surgical procedure is separately reportable with modifier 25." But in some cases, our doctor must perform a service for a related procedure during the same visit. Is the modifier no longer applicable for these services?

Answer: The new language has been confusing for quite a few practices, but Medicare lays your fears to rest with specific guidance on this topic.

CMS "does not require that the significant and separately identifiable E/M service and the minor surgical procedure be reported with different ICD-9 codes," a CMS spokesperson said earlier this week. "Both may be related to the same medical problem."

The CMS spokesperson points to the following citation from chapter 12, section 40.1, of the Medicare Claims Processing Manual:

"Visits by the same physician on the same day as a minor surgery or endoscopy are included in the payment for the procedure, unless a significant, separately identifiable service is also performed. For example, a visit on the same day could be properly billed in addition to suturing a scalp wound if a full neurological examination is made for a patient with head trauma. Billing for a visit would not be appropriate if the physician only identified the need for sutures and confirmed allergy and immunization status."

Therefore, if you perform an E/M service and a procedure on the same date, you can continue 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) or modifier 57 (Decision for surgery) on the E/M code, as long as the physician's documentation meets the requirements of the codes and the modifiers on the claim.