Neurosurgery Coding Alert

Answer to -separate vs. inherent- question is key to successful claims

If the neurosurgeon performs an E/M service and a procedure with a global period of up to 10 days on the same patient during the same encounter, you may be able to report the E/M separately using modifier 25.
 
But before using the modifier, you must prove that the E/M is a separate service and is not an inherent component of the procedure. Follow this advice to find out when to report an E/M with modifier 25 (Significant, separately identifiable E/M service by the same physician on the same day of the procedure or other service) and when to leave the E/M code off the claim.

Find Evidence of Separate E/M in Notes

In a nutshell: -Coders should use modifier 25 when a significant, separately identifiable E/M service is performed by the same physician at the same face-to-face encounter as a procedure or other service,- says Catherine Brink, CMM, CPC, president of Healthcare Resource Management of Spring Lake, N.J.
 
The most vital element on successful modifier 25 claims is concrete evidence that the procedure and E/M were truly separate, Brink says. All procedure codes have an inherent E/M component built into them, and the physician must go beyond that to justify a separate E/M. If the decision to perform the procedure results from the medical decision-making performed during the E/M service, you can separately report the E/M with modifier 25. In addition, the E/M service must also meet medical- necessity criteria and be totally separate from the
other procedure.   
 
For example: A patient reports to the neurosurgeon for two sacral joint injections. The surgeon briefly examines the injection area and performs the injections. Notes indicate a limited exam.
 
In this case, insurers aren't likely to accept a code for a significant, separately identifiable E/M service because the surgeon limited the exam to the treatment area.
 
So on this claim, you should report these codes:

 - 64475 (Injection, anesthetic agent and/or steroid, paravertebral facet joint or facet joint nerve; lumbar or sacral, single level) for the initial injection

 - +64476 (- lumbar or sacral, each additional level [list separately in addition to code for primary procedure]) for the second injection.
 
Try this one: Now check out this scenario, in which the neurosurgeon performs a procedure and a separate E/M service:
 
A new patient presents to the neurosurgeon complaining of neck pain, photophobia and a severe -10 out of 10- headache that has been present for more than a day. The neurosurgeon performs a level-four E/M service to address the symptoms. Fearing the possibility of subarachnoid bleeding, the neurosurgeon decides to perform a spinal tap based on her findings.
 
In this instance, the neurosurgeon provided two separately reportable services: the E/M and then the spinal tap. On the claim, use the following codes:

 - 62270 (Spinal puncture, lumbar, diagnostic) for the spinal tap

 - 99204 (Office or other outpatient visit for the evaluation and management of a new patient, which requires these three key components: a comprehensive history; a comprehensive examination; medical decision- making of moderate complexity) for the E/M

 - modifier 25 attached to 99204 to show that the E/M and spinal tap were separate services

 - 784.0 (Headache) and 723.1 (Cervicalgia) linked to 62270 and 99204 to prove medical necessity for both services.

You Could Have Same Dx for E/M, Procedure

As evidenced in the above example, you don't need a different diagnosis code for a separate problem to code an E/M with modifier 25. Sometimes, the circumstances justify a procedure and a separate E/M for the same complaint.
 
A good rule for modifier 25 claims is -if an E/M service was necessary for the physician to make a medical decision to perform the procedure -- and he had to take a history, perform an exam and come to a medical decision to perform the procedure -- then a separate E/M can be charged,- Brink says.
 
But when the neurosurgeon asks a few incidental questions of the patient prior to the procedure that amount to a limited exam, only report the procedure code.

Experts Agree: Solid Documentation Is the Best Way to Guarantee Modifier 25 Payment

On the claim for the previous example, you should make sure the notes for the E/M and the spinal tap stand separately, says Cindy Parman, CPC, CPC-H, RCC, co-owner of Coding Strategies Inc. in Powder Springs, Ga.
 
-Generally, we advise physicians not to bury the procedure in the patient visit note. It helps to have a separate paragraph from the E/M that states -procedure note- and includes a brief description of the procedures,- Parman says.
 
Check out what CPT Assistant 2004 has to say about modifier 25 claims: -Generally, separate documentation of each service (e.g., E/M and procedure) is recommended so that each service is readily and individually identifiable as such. Each may be documented separately in progress or other appropriate notes. Separate pages for each service are not required.-
 
You don't necessarily have to submit separate reports for the procedure and E/M, but you should provide the insurer with designated procedure documentation and E/M visit documentation.
 
Try this: When checking documentation for your modifier 25 claim, Brink recommends that you make sure there is medical necessity for the separate E/M. Remember, the encounter must satisfy three of three E/M components to report a new patient E/M service, and it must satisfy two of three components to report an established patient E/M.
 
Once you confirm that the notes clearly indicate a medically necessary E/M service that is separate from the procedure the surgeon performs, you-re ready to submit your modifier 25 claim.