Neurology & Pain Management Coding Alert

In October 2000, version 6.3 of the national Correct Coding Initiative (CCI) added more than 50,000 edits bundling E/M services to diagnostic tests performed on the same day. To receive separate payment, providers were instructed to attach modifier -25 (significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) to any E/M code filed on the same date of service as a diagnostic test. As a basis for this policy, CMS reasoned, 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.
 
For instance, if on the same day as a scheduled electromyogram (9586x, depending on the number of limbs) the patient presents with a new complaint that requires a separate history, exam and medical decision-making, this separately identifiable E/M service could be billed in addition to the test. Modifier -25 must be appended to the E/M code, however, to inform the payer that it was separate from the E/M component already included in the test.
 
In February 2001, CMS announced the retroactive suspension of the edits (memorandum B-01-09, Change Request 1546). The agency advised providers to resubmit any claims denied as a result of the edits, but continued to recommend that modifier -25 be appended to the E/M service code. Such claims must be resubmitted within a year of submission of the effective date of the 6.3 CCI edits. Because the edits became effective Oct. 1, 2000, the one-year deadline is fast arriving. Dont forget to resubmit your denied claims for payment as soon as possible.
 
Note: If a patient presented for just a diagnostic test, only the test should be reported. Claims incorrectly filed with a separate E/M service -- with or without modifier -25 appended -- when no such service was rendered should not be resubmitted.