Otolaryngology Coding Alert

Tip: All procedures include an inherent E/M component.

Every time you fail to report a legitimate and documented significant and 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 a 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 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, CPC-I, CCS-P, CPC-H, CCS, CPC-P, COBGC, CCC, audit manager for CHAN Healthcare in Vancouver, Wash.

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: Ask yourself, "Can I find in the documentation a clear history, exam and medical decision-making beyond a simple 'H&P' for the procedure?" If so, you have 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).

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 a 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 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 or different section of the note, for example, below the history, exam and MDM. When setting up your, EHR, the procedure note should be established as a separate document from the documentation of the EM service.

Make sure that the findings of a diagnostic procedure is not documented in the exam portion of the E/M service, but documented in the procedure note. The reason for performing the diagnostic procedure, such as "inadequate visualization," should be documented in the exam portion of the E/M. If the findings of the diagnostic procedure are documented in the exam, either the procedure cannot be supported by the documentation, or the bullet/body area/ organ system cannot be supported. You cannot double count any diagnostic procedure documentation for both the EM and the procedure.

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 239.1 (Neoplasm of unspecified nature of respiratory system) to the laryngoscopy. Had the laryngoscopy not yielded a definitive diagnosis, however, you could have linked the dysphagia complaint to that procedure, as well. The delinking for the complaint and definitive diagnosis assists in supporting the medical necessity when dealing with the third party payer, to support both the E/M service and the procedure.