Neurosurgery Coding Alert

Separate documentation must stress the E/M's distinct nature

If you expect reimbursement from insurers, any E/M service you bill at the same time as another procedure must be significant and separately identifiable. Learning a few tips, such as choosing proper diagnosis codes to report, will help solidify your E/M coding.

In CPT 2006, the American Medical Association includes additional explanatory text to clarify when you may report an E/M service with modifier 25 on the same day as another procedure or service.
 
The addition of these comments supports previous Medicare guidance instructing carriers not to automatically deny payment for E/M services billed with modifier 25, but with the same diagnosis code as another service provided on the same date. Get a jump on CPT and sharpen your modifier 25 skills with these four, expert-approved strategies.

1. Be Sure the E/M Is Significant

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 Falls, N.J.

Tip: -I recommend that coders do the -HEM- test--can you pick out from the documentation a clear history, exam and medical decision-making? If so, you-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. Separate Your 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.

The AMA takes a stand: Revised explanatory text for modifier 25 in CPT 2006 specifically stresses the importance of documentation and will instruct coders that 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.

3. Choose a (Related or Unrelated) Diagnosis

When reporting any E/M service, you must link the service to a diagnosis that explains the reason the physician performed the service. But the E/M service does not necessarily need to be different from or -unrelated- to the other service or procedure 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: A patient arrives for a consult because of a sudden, severe headache. The surgeon assigns a primary diagnosis of 784.0 (Headache), which she links to the consult (for example, 99243, Office consultation for a new or established patient ...). To rule out the possibility of meningitis or subarachnoid bleeding, the surgeon performs a spinal tap (62270, Spinal puncture, lumbar, diagnostic) in addition to the E/M service. Because the headache diagnosis prompted the spinal tap, you may use the same ICD-9 code (784.0) to support the spinal tap.

4. Append 25 to the E/M

The final step to guarantee payment for an E/M service on the same day as a procedure or other service is to append modifier 25 to the appropriate E/M service. Returning to the example above, for instance, you would report 62270 for the spinal tap and 99243-25 for the consult.

Next month: Proper use of modifiers 24 (Unrelated E/M service by the same physician during a postoperative period) and 57 (Decision for surgery), and how to differentiate them from modifier 25.