Otolaryngology Coding Alert

Keep your E/M and procedure documentation apart

Every time you fail to report a legitimate, separately identifiable E/M service, your practice misses out on anywhere from $25 to well over $100.

Don't let this happen to you: Here are three tips to help you know when and how to report separate E/M services with modifier 25.

Tip 1: Stress -Significance-
 
To gain payment for an E/M service the physician provides at the same time as another procedure or service, the E/M must be both significant and separately identifiable.

Why you need to be concerned: The Office of Inspector General (OIG) released a report on Dec. 12 that cites widespread misuse of modifier 25 and resulting overpayments by Medicare. The OIG went on to recommend that CMS should -encourage carriers to re-examine their modifier 25 outreach activities and include modifier 25 reviews in their medical review strategies where appropriate.-

All procedures, from simple injections to common diagnostic tests, include an -inherent- E/M component, according to CMS guidelines. Therefore, any E/M service you report separately must be -above and beyond- the minimal evaluation and management that normally accompanies such a procedure, says Marcella Bucknam, CPC, CCS, CPC-H, CCS-P, HIM program coordinator at Clarkson College in Omaha, Neb.

Note, however, that modifier 25 is not restricted to a particular level of service (such as a level-three exam or higher), according to the September 1988 CPT Assistant.

Example: A patient arrives for a previously scheduled diagnostic endoscopy, 31231 (Nasal endoscopy, diagnostic, unilateral or bilateral [separate procedure]). The ENT provides a cursory exam to assess the patient's fitness for the procedure. In this case, the level of exam, history and medical decision-making (MDM) are not significant enough to stand on their own as a separate E/M service.

Tip: -I ask myself, -Can I find in the documentation a clear history, exam and medical decision-making beyond a simple -H&P- for the procedure?- If so, I-ve got a separately 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.

Bottom line: You should consider a brief history and physical prior to a same-day scheduled outpatient procedure as an included component of the procedure itself.

Even if the physician provides an assessment and plan for a scheduled procedure, you probably should not report a separate E/M service unless the patient has a new, unrelated complaint or has had a worsening of symptoms that prompts a new history, exam and MDM process. This would probably include prescribing therapy or ordering other tests unrelated to the procedure.

Tip 2: Separate the Documentation

When reporting an E/M service on the same day as another procedure, physically separate the documentation for the E/M portion of the service from the other procedure(s) or service(s) the ENT provides. This demonstrates to the payer the E/M service's distinct nature, Jandroep says, and proves that the E/M service can -stand alone.-

Here's how: The ENT should document the history, exam and MDM in the patient's chart and record the procedure notes on a different sheet attached to the chart.

Tip: The Association of Otolaryngology Administrators (AOA) offers sample chart forms (templates) to members at www.oto-online.org. These templates allow you to easily separate your -procedure- documentation from your -E/M- documentation.

The AMA weighs in: For 2006, CPT specifies, -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.

Tip 3: An Unrelated Dx Helps But Isn't Required

When reporting any E/M service, you must link it to a diagnosis that explains the reason the physician performed the service.

Important: The E/M service needn't be unrelated to the other service(s) or procedure(s) the physician provides on the same day, Bucknam 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]. But separate diagnoses, when available, do further help to demonstrate the distinct nature of the E/M service.

Example: A new consult patient arrives with a complaint of difficulty swallowing. The ENT takes a complete history and performs an extensive exam. She then performs laryngoscopy, which reveals a mass in the larynx.

In this case, you will report the laryngoscopy (31575, Laryngoscopy, flexible fiberoptic; diagnostic). Separate documentation will also support a level-four or -five  outpatient consult (depending on the documented level of MDM) to which you should append modifier 25 (for example, 99244-25). You should link the complaint that prompted the exam (787.2, Dysphagia) to the E/M code, and link 212.1 (Benign neoplasm of larynx) to the laryngoscopy. Had the laryngoscopy not yielded a definitive diagnosis, however, you could have linked the dysphagia complaint to that procedure, as well.