Neurology & Pain Management Coding Alert

Separate documentation must stress the distinct nature of the E/M service

Revised explanatory text for modifier 25 in CPT 2006 will specify -a significant, separately identifiable E/M service is defined or substantiated by documentation that satisfies the relevant criteria for the respective E/M service- you choose to report. Here are three ways to ensure that your documentation is up to the task.

1. Stress -Significance-

 To gain payment for an E/M service the physician provides at the same time as another procedure or service, the E/M must be both 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 CRN Healthcare Solutions, a coding and reimbursement consulting firm in Tinton Fall, N.J.

Aim for level three or higher: Although CPT does not provide precise guidelines to define -significant,- many coding experts suggest that the physician should document at least a level-three service for an established patient (99213 or higher) before charging for a separate E/M.

Example: The neurologist provides a cursory examination prior to a previously scheduled electro-myographic (EMG) exam for upper-extremity weakness and pain. In this case, the exam alone does not exceed a level-one E/M service (99211), and therefore the service does not qualify as significant.

Tip: -I always ask, -Can I find in the documentation a clear history, exam and medical decision-making?- If so, I-ve got a billable service- with modifier 25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service), 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.

2. Physically Separate the E/M Documentation

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, Jandroep says.

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.

3. Choose an E/M Diagnosis

When reporting any E/M service, you must link the service to a diagnosis that explains the reason the physician performed the service.
 
Important: The E/M service needn't be -unrelated- to the other service(s) or procedure(s) 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].

Example: Our patient from the example above arrives for prescheduled EMG testing for upper-extremity weakness and pain. But in this example the patient states that the pain is worsening and making daily activities difficult to perform. Concerned by these developments, the physician takes an updated history, writes a prescription for pain management and counsels the patient on possible diagnoses and management options.

In this case, you will report the prescheduled EMG (for instance, 95861, Needle electromyography; two extremities with or without related paraspinal areas). Separate documentation will also support a level-three established-patient E/M service, to which you should append modifier 25 (99213-25). Because the E/M service resulted from the same complaint that prompted the EMG, you may link the same diagnosis (such as 729.5, Pain in limb) to both services.