Part B Insider (Multispecialty) Coding Alert

PART B Coding Coach:

Bolster E/M Coding With This 25/57 Advice

Published on Thu Aug 11, 2022

Established patient + new problem? Don’t assume billable E/M service.

There’s no denying that appending the right modifier to your Part B claims can be tricky. But, it’s critical that you understand the nuances surrounding modifiers 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) and modifier 57 (Decision for surgery) to ensure your claims are clean.

Understand Rules Apply Equally to New and Established Patients

You may have heard this common myth: If it’s an existing patient with a new problem, it’s an automatic E/M service. Remember that nothing is automatic without documentation to back it up.

Example: An established patient with an established diagnosis of carpal tunnel syndrome (CTS) reports for a trigger point injection (TPI). During the injection, the patient complains of hip pain. the provider writes a prescription for an anti-inflammatory and recommends physical therapy for hip pain.

Some providers think the notes above warrant billing an E/M service along with the immunizations. “Just writing the prescription or finding a different diagnosis doesn’t get us to significant and separately identifiable E/M. We need a robust paragraph of evaluation and management,” says Jeffrey Lehrman, DPM, FASPS, MAPWCA, CPC, CPMA, principal, Lehrman Consulting LLC, Fort Collins, Colorado, during his HEALTHCON presentation, “What Exactly Is a Significant and Separately Identifiable E/M?”

Better option: Let’s say the note had instead said something like this: During routine visit, patient complained of hip pain. After the TPI, there was discussion that included duration of the pain, possible causes, family history of arthritis. I checked range of motion and degree of pain. The advantages and disadvantages of physical therapy and anti-inflammatory medications were discussed, and a prescription was written for both X-rays ordered.

The difference between the two sets of notes is clear. The patient came in for their preventive procedure and had a chief complaint of hip pain, which required a completely separate E/M. The work for each didn’t overlap, and the documentation clearly showed that there was both evaluation and management.

Separate Dx not Always Needed

Sometimes, there are instances of significant and separately identifiable E/M services that don’t carry an additional diagnosis.

“A separate diagnosis code is not necessary for the use of an E/M code with modifier 25/57,” confirms Chelle Johnson, CPMA, CPC, CPCO, CPPM, CEMC, AAPC Fellow, billing/credentialing/auditing/coding coordinator at County of Stanislaus Health Services Agency in Modesto, California.

Know What to Look for in the Patient Record

“Modifier 25/57 can be tricky to get used to determining,” says Johnson. Remember that the documentation must fully describe the additional E/M service. “If the documentation just supports the procedure, the use of an additional E/M with modifier 25/57 would not be appropriate,” she says. If you suspect the practitioner’s work warrants use of the modifier and their documentation does not, it’s important to communicate that to them directly so they fully understand what to document.

Documentation example: For an E/M service that is significant and separately identifiable from a procedure, an auditor is going to want to see that clearly in the notes. “If you’re a provider or you’re looking for something to communicate with your provider, I suggest a paragraph to physically separate the two services,” explains Lehrman. “This is my suggestion as an auditor. Begin the paragraph with something like this: ‘patient has a separate complaint today …,’ then after documenting the evaluation and management of that complaint, the last sentence should be, ‘This evaluation and management of the _________ was significant and separately identifiable from the procedure of ____________,’” he says.