Otolaryngology Coding Alert

Rely on these specific guidelines from the Global Surgery Booklet.

In Volume 21, Issue 3 of Otolaryngology Coding Alert, you refined your cerumen coding skills in the article Bank on this Definitive Guide to Cerumen Removal. One of the main talking points in this article focuses on what cerumen removal circumstances do and do not allow for the use of modifier 25 (Significant, Separately Identifiable Evaluation and Management Service by the Same Physician or other qualified health care professional on the Same Day of the Procedure or Other Service).

While understanding the vast array of dynamics and nuances that drive the use of modifier 25, there’s one area that remains a mystery to coders, practice managers, and physicians alike — new patient office visits involving procedures.

Use this guide to help clear up any confusion on when and when not to bill for a new patient evaluation and management (E/M) visit in addition to a minor procedure.

Avoid This Common Misconception

One popular misconception within the field of E/M coding concerns first-time patients that undergo a minor surgical procedure. Contrary to popular belief, it’s not always necessary to include an E/M visit code with modifier 25 for these patients. Consider the following scenario:

• A new patient makes an appointment with an otolaryngologist to treat a »»buildup of impacted cerumen. The otolaryngologist confirms the patient has bilateral impacted cerumen and proceeds to remove the cerumen using wax curette and cup forceps.

You’ve got to take numerous factors into consideration surrounding this patient’s chart before knowing whether to exclusively report 69210 (Removal impacted cerumen requiring instrumentation, unilateral) or bill separately for an E/M visit using modifier 25. “It’s initially important to understand that code 69210 contains some inherent E/M within it,” says Marie Popkin, BS, CPC, coding supervisor at Aviacode in Salt Lake City, Utah. “If you look at the Centers for Medicare and Medicaid Services [CMS] time file for this code, it will tell you how much pre- and postoperative time as well as intraoperative time this would take, on average,” Popkin explains.

Subscribe to These Global Surgery Guidelines

In examining the above scenario, you first need to rely on the patient’s chart to determine whether there was enough “extracurricular” activity that occurred outside of the cerumen removal to report a separate E/M visit. Have a look at one of numerous CMS Global Surgery Booklet policies instructing you on how to address office visits involving minor procedures:

• “Visits by the same physician on the same day as a minor surgery or endoscopy are included in the payment for the procedure, unless a significant, separately identifiable service is also performed.”

In the case of a new patient, it’s important to point out that this doesn’t necessarily have to involve a significant, separately identifiable condition that needs treatment. Rather, what if the physician spends extra time and effort inquiring about past ENT-related conditions in order to get further acclimated with the patient? Determining whether this justifies a separate E/M code requires the coder to have a better understanding of what CMS includes in a minor surgical procedure. To do this, you have to consider a few important sets information, such as the policy above, included in CMS’ Global Surgery Booklet.

For the sake of practicality, the types of minor procedures discussed in this article will qualify as procedures with a global period of 0 days. This means that the payment for the physician’s services does not include any work outside of the day of the minor procedure. With that said, there are some instructions that CMS includes to give coders an idea of what services are included in the global surgery payment for procedures with a global period of 0 days.

First, CMS includes the following services in the global surgery package:

• “Preoperative visits after the decision is made to operate beginning with the day before the day of surgery for major procedures and the day of surgery for minor procedures.”

Additionally, CMS outlines what services are not included in the global surgery package:

• “The initial consultation or evaluation of the problem by the surgeon to determine the need for surgery. Please note that this policy only applies to major surgical procedures. The initial evaluation is always included in the allowance for a minor surgical procedure.”

Using the cerumen removal example above, you now know that an underlying “initial evaluation” is already included in the payment for the cerumen removal procedure. The question now becomes, how do you distinguish between those physicians performing a routine “initial evaluation” and those physicians whose work justifies a “significant, separately identifiable” service?

See What Else Might Constitute Modifier 25 Use

Obviously, when the patient presents with a significant, separately identifiable condition that the physician evaluates and treats, then the answer is easy. Report the E/M visit with a modifier 25 in addition to 69210. But if you go back to the case where the physician performs a moderate historical checkup on previous conditions affecting the patient, you should consider whether you’ve got enough documentation to support a separate, low-level E/M visit to report alongside the cerumen removal.

If you feel that the documentation supports physician work that extends beyond what CMS includes in a precursory exam prior to a minor procedure, you may separately report a low-level E/M visit. However, it’s important that you use caution while doing so. If you feel that, separate from the pre-service work involved in performing the minor procedure, there’s still enough separate history, exam, and medical decision making (MDM) documentation to report a separate E/M visit, then it’s certainly appropriate to do so.

Coder’s note: “Keep in mind that the separate and significantly identifiable E/M visit must be documented separate from the procedure note,” details Barbara J. Cobuzzi, MBA, CPC, COC, CPC-P, CPC-I, CENTC, CPCO, AAPC Fellow, of CRN Healthcare in Tinton Falls, New Jersey. “This means that the removal of the impacted cerumen detail should not be documented in the ’ear bullet’ in the E/M exam. It needs to be a separate procedure note. The documentation in the ’ear bullet’ in the exam can refer to the impacted cerumen and the procedure note found elsewhere in the documentation. The procedure note is often found between the Exam and the Assessment and Plan in many electronic health records (EHRs),” Cobuzzi explains.