Practice Management Alert

E/M-25 service must exceed E/M built into procedure code.

If your physician performs a procedure and a separate evaluation & management (E/M) service for the same patient during the same encounter, you might be able to report an E/M code in addition to the procedure.

How? The E/M service must be separately identifiable, and you must append 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) to the E/M code.

Check out these modifier 25 basics to get better at spotting extra E/M opportunities on your provider’s claims.

Find Pre-Procedure E/M Before Employing 25

You can only use modifier 25 on E/M codes, and you can only report these codes along with a procedure code when “an E/M service is separate and significant from another procedure or service at the same encounter,” explains Melanie Witt, RN, CPC, MA, an independent coding expert based out of Guadalupita, N.M.

“This does not mean that a different diagnosis is required, but the note must clearly indicate that the E/M dealt with issues that were not part of the other services,” Witt explains.

When you are reporting an E/M with modifier 25, you will almost certainly code a procedure on the same claim. Before the physician performs any procedure, he will perform elements of an E/M service: reviewing patient history, explaining the procedure to the patient, answering questions concerning the procedure, obtaining informed consent, etc.

Payers consider this E/M service part of the work units associated with the procedure. “Counting any of these items toward a separate E/M service would not be appropriate,” Witt explains.

You should only look for a separate E/M when notes indicate that the physician treated a problem separate from the procedure or other service on the same patient during the same encounter.

Earn $75 More by Spotting This E/M-25

Consider this example from Witt, in which the provider performs an E/M and then a knee treatment for the same patient:

Example: An established patient reports for a periodic follow-up for hypertension and type 2 diabetes (well-controlled by diet). During the visit, the patient complains of right knee pain he suffered while doing yard work. The physician performed an expanded problem-focused history and exam of the patient’s hypertension and diabetes, and refilled the patient’s hypertensive medication. Then the physician evaluated the knee and performed an arthrocentesis; there is no mention of ultrasound guidance in the notes.

On this claim, you would report 20610 (Arthrocentesis, aspiration and/or injection, major joint or bursa [e.g., shoulder, hip, knee, subacromial bursa]; without ultrasound guidance) for the arthrocentesis and 99213 (Office or other outpatient visit for the evaluation and management of an established patient,   which requires at least 2 of these 3 key components: an expanded problem focused history; an expanded problem focused examination; medical decision making of low complexity…) for the E/M service with modifier 25 appended to show that the arthrocentesis and hypertension/diabetes E/M were significant, separately identifiable services.

For diagnosis coding, you should append I10 (Essential [primary] hypertension) and E11.9 (Type 2 diabetes mellitus without complications) to 99213 to represent the patient’s hypertension and diabetes; and M25.561 (Pain in right knee) to 20610 to represent the patient’s knee injury.

Explanation: The evaluation and treatment of the patient’s knee problem is part of the work units for 20610. The physician also performed a separate E/M to address the patient’s hypertension and diabetes. The physician would have performed the separate E/M “even if the knee problem did not exist, making the use of modifier 25 appropriate,” Witt explains.

The number$: In this example, spotting the additional E/M results in almost $75 more for your practice. According to the Medicare Physician Fee Schedule, 99213 has 2.04 total nonfacility relative value units [RVUs]. When you multiply the RVUs by the 2015 Medicare conversion factor of 35.9355, you’ll get a national average payout approaching $75.

Code Separate E/M If It Could Stand Alone

If you are having trouble figuring out if there was a separate E/M, Mary I. Falbo, MBA, CPC, CEO of Millennium Healthcare Consulting, Inc. in Lansdale, Pa., recommends asking yourself the following questions:

• Did the physician perform and document the key components of a separate problem-oriented E/M service for the complaint or problem?
• Could the separate complaint or problem stand alone as a billable service?
• Is there a different diagnosis for this portion of the visit?
• If the diagnosis will be the same for the entire visit, did the physician perform extra work that went above and beyond the typical pre- or postoperative work associated with the procedure code?

If you answered “yes” to any or all of these questions, you might be able to report an extra E/M with modifier 25.

Proper Documentation a Must for E/M-25 Success

Without documentation proving that the patient’s condition required a separately identifiable treatment, your E/M-25 claims could face denials.

You can substantiate a significant, separately identifiable E/M service with documentation that satisfies the relevant criteria for the separate E/M you’re reporting, says Falbo. This means that, basically, the physician established a separate plan of care for a separate problem during the E/M-25, she says.

Best bet: You should have your documentation in order before filing the claim, even if you don’t send it in with the initial claim. Often, the payer won’t require you to submit any documentation with the initial claim. If they deny your E/M-25, however, you will need to produce documentation for a successful appeal.