Practice Management Alert

Medical office billers who frequently report modifier 25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) on claims are used to carriers paying close attention to the claims, but supporting these claims just got more involved.

Why? Your documentation for modifier 25 will be under heavy scrutiny soon, judging from Transmittal 954, issued May 19 by the Centers for Medicare & Medicaid Services. In this transmittal, CMS:

- adds the word -usual,- so the rules now read: -a significant, separately identifiable E/M service that is above and beyond the usual pre- and postoperative work for the service.- The addition is just meant to emphasize that any extra E/M service must be -above and beyond- the typical pre-op or post-op work, says Quinten Buechner with ProActive Consultants in Cumberland, Wisc.

- clarifies that you don't need a different diagnosis for the E/M service and surgery.

- stresses that you must make sure you have appropriate documentation proving the medical necessity of the separate same-day E/M service. You don't need to submit this documentation with the claim, but it must be available upon request.

It's safe to say that modifier 25 claims -will be under more scrutiny,- but none of these changes are major, says Lisa Center, coder with Mount Carmel Regional Medical Center in Pittsburg, Kan.

Bottom line: If your doctor already plans a procedure and does a pre-op workup, don't bill for a separate E/M. But if the physician doesn't know whether a procedure will be necessary and must perform an E/M service to rule out other options, you can bill for the E/M in which the doctor reaches the decision for surgery, Center says.

Example: A new patient comes in with three skin lesions on his trunk, and the physician does an excisional biopsy of one of them. The physician takes a history and a review of systems, takes a family history of malignancy, and examines the patient's integumentary and lymph systems, as well as the neurological system. Then the physician decides which lesions to remove and removes them.

If you document everything that happened, you can easily bill for a separate E/M service along with the excisional biopsy (CPT code 11100) and lesion removal (codes 11400-11406). But if the physician only documents that he examined and removed some lesions and did an excisional biopsy, you can only bill for the procedures.