Practice Management Alert

File an E/M without all 3 components, and expect a denial

When a patient reports to your medical office for treatment of a specific injury or illness, the physician always performs some evaluation and management service along with the procedure.

Questions: Which E/M services does CPT bundle into the procedure code, and how can you tell if an encounter involved enough service to report a separate E/M?
 
If you can't answer these questions, you won't know whether it is possible to report a separate 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) in addition to the procedure code. 

Answer:  Identify Procedures With Inherent E/Ms When a patient presents to your office for a procedure, your physician will provide certain services that are components of the procedure code and cannot be reported as separate E/Ms.

-If a patient came in for a laceration repair, the physician is not going to just jump right in and start suturing. She is going to first talk about how the injury occurred, assess the wound, and decide what suture material to use, etc.,- says Laureen Jandroep, OTR, CPC, CCS-P, CPC-H, CCS, CPC-EMS, coding analyst for New Jersey's CodeRyte Inc., national speaker, teacher of coding review courses, and former AAPC National Advisory Board member.
 
But you-ll have to know when to bill for modifier 25 and when not to. For example, a physician performs a procedure and a separate level-one E/M on a new patient. You should report the procedure code and 99201 (Office or other outpatient visit for the evaluation and management of a new patient, which requires these three key components: a problem-focused history; a problem-focused examination; straightforward medical decision-making) with modifier 25 appended for the encounter.

Consequences: If you do not recognize that you can bill the 99201-25, the office loses Medicare reimbursement of $39.21. Conversely, if you bill for a separate E/M that the physician did not provide, you could face huge fines and penalties. Watch for These 2 Potential Modifier 25 Scenarios There are two main scenarios in which patients might require a procedure and a significant, separate E/M during the encounter. Some patients--such as a car crash victim with multiple lacerations, possible broken bones and a potential concussion who reports to the ED--will always require significant, separate E/M.

During other encounters, the physician might also provide separate E/Ms when a patient reports for a procedure or service, then adds a totally separate complaint during the encounter.

-It's what I call the -Oh, by the way- complaint. While the doctor is in there to do a procedure, the patient says, -Oh, by the way, can you look at this, it has been [...]