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. 1. Low-Level E/M Services Are Not 'Significant' 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 [...]