Part B Insider (Multispecialty) Coding Alert

New book may be adding to the confusion

Coders are reporting denials for evaluation and management claims on the same day as a minor surgery, even if they use modifier -25.

Some payers are citing a recent book from the American Medical Association, Coding With Modifiers, as backing up the association's hard-line stance. The book says you shouldn't use modifier -25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) with E/M services "associated with procedures" - unless the E/M is "above and beyond the usual preoperative and postoperative care associated with the procedure."

While this wording is in line with longstanding AMA policy, some observers fear it could prove confusing to coders and payers. You should be able to bill for an E/M that's related to a same-day procedure with a 10-day global period as long as you do more work than the usual "no or go" pre-operative examination.

The gray area is when a patient comes in with a new problem and the physician examines the patient, then performs a minor procedure to correct the problem.

For example, if a patient has fallen and cut his forehead open, and the doctor merely glances at the wound and confirms that it needs stitches, the doctor shouldn't bill for an E/M separate from the stitching, says consultant Quinten Buechner with ProActive Consultants in Cumberland, WI. But if the physician checks the patient for concussion and other problems before stitching, that justifies a separate E/M.

The author of Coding With Modifiers, consultant Deborah Grider with Medical Professionals in Indianapolis, is more conservative. She gives this example: a patient comes in with knee pain and the physician diagnoses fluid in the joint, then performs an arthrocentesis. If the patient also needs diabetes counseling, then you can report the counseling separately and attach modifier -25 to the E/M to receive payment for this service and the procedure.

But if the physician only examines and diagnoses the patient's knee pain and decides to perform an arthrocentesis, you should consider the exam a pre-operative work-up and only bill for the procedure, says Grider.

Although this is a gray area, you should be able to use modifier -25 with a "new onset problem" that requires a work-up and then leads to a procedure, insists Jo Anne Steigerwald, senior consultant with the Wellington Group in Valley View, OH. For example, if a patient comes in with bursitis, the doctor needs to examine the patient and then explain why he needs to perform the necessary procedure.

In the past, you couldn't use modifier -25 if the E/M had the same diagnosis as the procedure. But the AMA added language to the CPT manual in 1996 that said you could use modifier -25 for two services linked to the same symptoms or condition, says Steigerwald.