Ob-Gyn Coding Alert

Question:We quite often bill a well woman and sick visit on the same day if the sick visit warrants a separate code for it. We use a modifier 25 for the E/M code. The claim usually processes with a patient's carrier with no problem. However, one of our insurance carriers recently has started to process the E/M code at 50-percent of the allowable and states, "This procedure has been paid at 50-percent of the reasonable and customary rate, due to multiple procedures performed on same date." Does that multiple procedure rule apply to E/M codes? I would think no, because coders are supposed to use modifier 25 for E/M codes only and use a different modifier for multiple procedures. That, to me, indicates that E/M services do not use the same rules. Is my logic making sense? Or should I just tell my docs to reschedule the WWE and E/M visits for two separate dates, so that we don't run into this problem?

New Hampshire Subscriber

Answer: E/M services and multiple procedures do not have the same CPT® rules, but payers are free to establish any rules they want. Most likely their rationale is that you did not make the appointment twice, did not use the room twice, the patient did not see the provider twice or use office supplies twice, so they are keeping part of the money.

Best Bet: Have your practice reschedule either the problem visit or the well woman exam (WWE) instead of trying to cram it all into one visit. Keep in mind this will take patient education to avoid misunderstandings about the services you will provide when your patients schedule their WWE.