Neurology & Pain Management Coding Alert

4 steps put you on the path to better reimbursement

Modifier -25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) 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.

Don't let this happen to you! A new patient arrives for a consult with the neurologist with a possible diagnosis of carpal tunnel syndrome (354.0). The neurologist provides a full E/M service, spending about 40 minutes taking the patient's history, performing an exam and, finally, deciding to conduct several electrodiagnostic tests, including electromyogram (EMG) and nerve conduction study (NCS), which she administers during the same visit.

To report the visit, you claim the appropriate test codes (for example, 95860, Needle electromyography; one extremity with or without related paraspinal areas and 95900, Nerve conduction, amplitude and latency/velocity study, each nerve; motor, without F-wave study), 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 it has refused payment for the consult, shortchanging your practice over $100 for a service properly rendered and documented.

If you want to avoid such expensive lessons, follow these four points 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 the physician normally provides 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. Significance is particularly important for E/M services provided at the same time as a diagnostic test (such as EMG, NCS, etc.) because the "included" pretest evaluation is not very substantial. Documentation should indicate that the physician provided a significant service and demonstrate that "double-dipping" has not occurred.

Aim for level-three or higher: Although CPT does not provide precise guidelines to define "significant," coding experts generally agree that the physician should document at least a level-three service before charging for a separate E/M. For example, the physician provides a cursory examination because of a new patient complaint during a previously scheduled procedure. In this case, the exam by itself does not exceed a level-one or -two E/M service (e.g., 99211 or 99212), so the service is not significant and you should not report it separately.

"I recommend that coders do the 'H.E.M.' 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.

Second: Physically 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 there is no requirement 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 suspected carpal tunnel syndrome, the neurologist would link the same signs and symptoms diagnoses (e.g., 719.44, Pain in joint; hand; 726.4, Enthesopathy of wrist and carpus; 782.0, Disturbance of skin sensation; etc.) to the E/M service as she links to the EMG and NCS codes.

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

Coding Example #2: The patient arrives for a pre-scheduled appointment for diagnostic testing of carpal tunnel. During the visit, the patient complains of low-back pain. The neurologist administers an EMG and NCS, linking the tests with signs and symptoms codes as described above. He also conducts a separate E/M for the back pain, matching an appropriate diagnosis (for example, 724.2, Lumbago) with the E/M code.

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 the first example above, for instance, you would report 95860 for the EMG, 95900 for the NCS, and 99243-25 for the consult.

Remember: "Modifier -25 is for E/M services only," Jandroep says.