Modifier -25 Key to Getting Paid for E/M Service and Procedure on the Same Day
Published on Wed Sep 01, 1999
If a patient comes to your practice for an office visit because her left breast hurts and she feels a lump, and you perform a breast cyst aspiration, how would you code to make sure both the visit and the procedure get paid even though they occurred on the same day?
This is just one of many situations ob/gyns face when dealing with an E/M service and a procedure on the same day. To receive the optimal amount of reimbursement, the coder must measure the appropriate evaluation and management (E/M) level of service for an office visit, provide the modifier -25if an E/M service is performed in addition to a procedureand give the correct procedural code for the additional service. (For more information on determining the level of E/M service, see the next column.)
Correct Use of Modifier -25 is Key
A patient can come in for an E/M service and require a procedure on that same day, states Amy Blum, a medical classifications specialist, specializing in ob/gyn, for the National Center for Healthcare Statistics in Washington, DC. And the ob/gyn can receive reimbursement for both, as long as the patients record has the appropriate
ICD-9 codes and the modifier -25 with the E/M code.
In the above situation, you would code the procedure 88170 (fine needle aspiration, with or without preparation of smears; superficial tissue [eg, thyroid, breast, prostate]), and the office visit would be 99211-99215 (established patient) with the modifier -25 (significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) attached to the E/M code.
The diagnosis does not have to be different for both the E/M and additional procedure; CPT 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.
Determining Proper E/M Level of Service
You are allowed only one E/M code per day, so it is best to choose that code discerningly. The level of the E/M service depends on three key components: history, examination, and medical decision making. It is worth mentioning that many physicians are still mistakenly basing this coding on time spent with the patient, rather than following the criteria set forth in the E/M section of CPT. Coding must be based on written documentation and medical decision making involved with the visit.
There are four types of history (problem focused, expanded problem focused, detailed, and comprehensive), and each type may or may not include these elements (see sidebar for definitions): chief complaint (CC); history of present illness (HPI); review of systems (ROS); and [...]
