Orthopedic Coding Alert

Determine how many body systems you must examine to qualify for 99214 If your practice's new year's resolution involves submitting audit-proof E/M claims, we-ve got good news for you. Check out the following three frequently asked E/M coding questions and our expert responses to keep your E/M payments accurate. Go Above and Beyond for E/M With Procedure Question: How can we determine if our hand surgeon's evaluation before a procedure (such as an EMG test) is separately billable, or if it is included in the procedure? Answer: If you have a hard time determining what constitutes a separate E/M service when your surgeon performs a procedure, remember that the physician needs to document a significant, separately identifiable service.

For every procedure your physician performs, he must complete at least a cursory history and physical (H&P) on the day of the procedure. So, to report a separate E/M service, your physician must document a service that is above and beyond the pre- and postoperative care associated with the procedure.

For example: A patient with carpal tunnel-like symptoms arrives for an initial consultation with the hand surgeon. The physician takes a full history, examines the patient and conducts electromyography and nerve conduction studies.
 
In this case, you should report the appropriate test codes (for example, 95860, Needle electromyography; one extremity with or without related paraspinal areas, and 95900, Nerve conduction, amplitude and latency/velocity study, each nerve; motor, without F-wave study), along with 99243 (Office consultation for a new or established patient ...) for the E/M service.

Because you are billing the test codes and the E/M service on the same date, you should append modifier 25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) to 99243.

Keep in mind: Modifier 25 still applies, even if the patient presents twice in the same day, once for a service and once for an E/M. For example, suppose a patient presents early in the day for an injection (for example, 20552, Injection[s]; single or multiple trigger point[s], one or two muscle[s]) for neck pain (723.1) and the physician does not perform a separate E/M during that visit. Later in the day, the patient begins to feel dizzy and nauseated. Fearing an adverse reaction to the injection, the patient returns to your office. The physician evaluates the patient and documents a level-three E/M service (99213, Office or other outpatient visit for the evaluation and management of an established patient ...).

In this case, you must still append modifier 25 to 99213. Although the injection and E/M service occurred at separate patient encounters, they still occurred on the same date of service. Don't Forget Medical Necessity Question: The [...]