Pediatric Coding Alert

Solid chart note and payer's rule will help you win payment What should you do when a payer sends you an E/M rejection with a procedure or service claim?

Should you:
 a. look at your documentation?
 b. check the insurer's policy?
 c. contact the payer's medical director?
 d. appeal citing HIPAA and CPT rules? Actually, coding experts recommend you do all four. Here's why: 1. Verify Encounter Meets Modifier -25 Criteria You should first check that your chart note supports billing the E/M with modifier -25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service). "Every procedure has a small E/M built into it," says Kay Faught, coding consultant for CPT Coding and Clinic Management in Jacksonville, Ore. So you must show that you performed a significant, separate service from the procedure or other service.

Example: You give a patient a shot in the arm, such as 95115 (Professional services for allergen immunotherapy not including provision of allergenic extracts; single injection). "The procedure has a little bit of evaluation in it," Faught says. To also code an E/M, for instance 99212-99215 (Office or other outpatient visit for the evaluation and management of an established patient ...), you must document a history, evaluation and medical decision-making apart from that included in the injection.

Tip: If your chart note's E/M documentation can stand on its own, fight for modifier -25 pay, if no carrier policies disallow the particular code combination, such as a same diagnosis E/M with allergen immunotherapy. You don't have to write the notes on a separate sheet, but visually separating the services or service and procedure will help show you whether the E/M "meets the test of water," says Victoria S. Jackson, CEO of Southern Orange County Pediatric Association with 11 pediatric offices in California.

Example: If you're coding an office visit in addition to a preventive medicine service (99381-99397), enter each service in a different box or template. To code the modifier -25 service, the office visit must contain a history, evaluation and treatment, Jackson says. "If no treatment exists, such as with a rash, you can't code the separate E/M." 2. Read the Payer's Rules Some insurers will not pay for an E/M service in addition to certain procedures or other E/M codes, regardless of your documentation. And if your contract specifies these restrictions, you shouldn't waste time appealing the decision.

Better method: Know your payers' rules. If your contract includes rules that require you to report services differently from CPT guidelines, you must follow them. But make sure to address these variations when your contract comes up for renewal.
 
Payer bundles "vary across the country," Faught says. Midwest insurers don't impose too many modifier [...]