Neurology & Pain Management Coding Alert

Modifier -25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) allows separate payment for an E/M service provided the same day as a procedure or other service if the physician can prove that specific documentation requirements have been met. Three points can help you append the modifier appropriately and gain fair reimbursement for services rendered while avoiding audit worries.

CMS policy dictates that all procedures, from simple injections to common diagnostic tests, include an inherent E/M component. Therefore, to be paid separately, any additional E/M service must be significant and separately identifiable, i.e., above and beyond the E/M service normally provided as a part of the procedure billed. And you must specifically document the separate E/M service in the medical record.

In the absence of specific guidelines from CMS, many coding experts have determined that an E/M service should qualify as at least a level-three encounter to be "significant," says Arlene Morrow, CPC, an independent coding and reimbursement specialist in Tampa, Fla. You must document all the components taken into account when determining the level of the visit including time, effort, complexity and treatment options to verify that the visit was indeed significant, she adds.

If, for example, the physician provides a cursory examination because of a new patient complaint during a previously scheduled procedure, but the exam by itself does not exceed a level-one or -two E/M service (e.g., 99211 or 99212), the service is not significant enough to be separately reported or reimbursed: One or two questions directed to the patient do not qualify as a significant E/M service. If a new complaint necessitates a higher-level E/M, however, such as 99214 (Office or other outpatient visit for the evaluation and management of an established patient ...), the service is significant enough to qualify for separate reimbursement.

Modifier -25 usually is not appropriate for a previously scheduled procedure. Physicians will often perform a quick patient review on the same day as a scheduled procedure, but most will not include an exam or medical history. In these cases a separate E/M service cannot be billed because the brief encounter is part of the procedure: A limited exam is integral to the procedure and therefore neither significant nor separately reportable.

Significance is particularly important for E/M services provided at the same time as a diagnostic test because the pretest evaluation included in the test's relative value is generally not very substantial. Documentation indicating that the physician provided a significant service demonstrates that "double-dipping" has not occurred, Morrow says.

An effective method to stress the separately identifiable nature of an E/M service is to physically separate the E/M notes from the procedure notes in the medical record, says Susan Callaway, CPC, CCS-P, an independent coding specialist and educator in North Augusta, S.C. 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 two services are clearly identified and are individually supported by documentation.

The requirement that an E/M service be separately identifiable to qualify for modifier -25 is an attempt to differentiate between E/M services included as part of a larger procedure/service and those that go beyond the usual pre- or postprocedure evaluation and care. Payers and providers have sometimes interpreted this to mean that a second, distinct diagnosis is required to bill a separate E/M service, but this is incorrect, Callaway says.

Likewise, there is no requirement that the E/M service be "unrelated" to the other service or procedure provided. 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." In all cases, however, if a second (related or unrelated) diagnosis is available, you should report it.

For example, a patient arrives for prescheduled electromyographic (EMG) testing of upper-extremity weakness and pain. During the visit the patient states that the pain is worsening and making it difficult to perform daily activities. 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, the documentation supports a level-three (99213) E/M service in addition to the EMG, e.g., 95861, Needle electromyography, two extremities with or without related paraspinal areas. Because the E/M service resulted from the same complaint that prompted the EMG, however, the same diagnosis (e.g., 729.5, Pain in limb) is linked to both codes.

In a second example, a patient is referred to the neurologist because he has had increasing weakness in the lower extremities. The patient's primary-care physician makes no tentative diagnosis and requests the consultation and electrodiagnostic testing to help determine a diagnosis. During the visit, the consulting neurologist learns that the patient's weakness occurred first on the left, over the last month, and has progressed to the right during the previous week. The neurologist further discovers that recently the patient has developed some slowness of urinary stream but with intact sensation. The patient also exhibits decreased strength in both legs and has a slightly "wide based" gait, but without significant loss of balance. Based on his or her E/M service, the neurologist has concerns about central nervous system diseases and determines that additional evaluation (including diagnostic testing) is required.

In this case the E/M service provided by the neurologist was essential to determining the most effective diagnostic tests. An E/M code is clearly appropriate in addition to any diagnostic tests performed. The differential diagnosis may be different for the E/M and the testing (or, as in this case, there is no differential diagnosis for the E/M), although the signs and symptoms diagnoses used for each are probably similar.

Like modifier -25, modifier -57 (Decision for surgery) appends to E/M services but is rarely used by neurologists. Modifier -57 is appropriate only if, during the patient evaluation, the physician determines that a major surgical procedure (i.e., a procedure with a 90-day global period) is necessary. In most cases, a surgeon will make this determination. The modifier indicates to the payer that the E/M service to which it is appended should not be included in the global package of the surgery because it was the visit where the decision for surgery was made and not part of the preoperative examination.