Neurology & Pain Management Coding Alert

Question: How should I report 62270 and 99233 when both are performed on the same day?I used modifier -59 on 62270, and Medicare paid for it but denied 99233.

Neurology Discussion List Participant

Answer: According to CMS guidelines published in the Nov. 2, 1999, Federal Register for selected procedures that have a global period indicator of "XXX," as well as procedures such as 62270* (Spinal puncture, lumbar, diagnostic) that include zero, 10 or 90 global days, if a significant, separately identifiable E/M service beyond that usually associated with the reported procedure occurs on the same day, modifier -25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) must be appended to E/M service code. "The basis for this policy," CMS states, is that "because every procedure has an inherent E/M component, for an E/M service to be paid separately, a significant, separately identifiable service would need to be documented in the medical record. In other words, we want to prevent the practice of physicians reporting an E/M service code for the inherent evaluative component of the procedure itself."

If only the spinal puncture was performed, only 62270 may be reported. If the patient presents with a new problem that prompted the spinal puncture or that required the physician to provide an E/M service in addition to a previously scheduled spinal puncture, 62270 and the appropriate E/M code (e.g., 99233, Subsequent hospital care, per day, for the E/M of a patient ) may be reported.

Substantiating the significant, separately identifiable nature of an E/M service is particularly important if it is provided at the same time as a diagnostic test (as is the case here) because the pretest evaluation included in the test's relative value is usually not very substantial. Documentation indicating that a significant service was provided demonstrates that "double-dipping" has not occurred.

An effective method to stress the separately identifiable nature of an E/M service is to separate the E/M notes from the procedure notes in the medical record. In other words, 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, the E/M service and procedure are individually supported by documentation.

In addition, whenever possible, provide a unique diagnosis for the E/M service and the procedure. But, a separate diagnosis for the E/M service is not required (for instance, if the E/M led to the decision to perform the procedure).

You do not need to append modifier -59 (Distinct procedural service) to 62270 in this case. According to CPT, "Modifier -59 is used to identify procedures/services that are not normally reported together, but are appropriate under the circumstances." Such circumstances may include: