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 bothering me.- And the doctor works it up with a [separate] history, exam, and medical decision-making,- says Barbara Cobuzzi, MBA, CPC, CPC-H, CHBME, of CRN Healthcare Solutions in Tinton Falls, N.J.

But for insurers to accept any claim with a procedure code and E/M-25, you have to convince them the physician provided -something more than the minor E/M that is included with the procedure,- Cobuzzi says.

Try the -HEM Rhyme-

Deciding whether your physician has provided a separate E/M in addition to a distinct procedure can be challenging, but Jandroep has developed a little trick that she relays to coders. -I teach a little rhyme that seems to help people remember: -If you don't have a HEM, you can't bill an E/M,- - she says.

Of course, the letters in HEM stand for -History,- -Exam- and -MDM,- the three key components of E/M services. -If you can't see those three components separate from the procedure note, then you most likely don't have a separate E/M service,- Jandroep says.

Consider this encounter, in which a physician performs a procedure and provides a significant, separate E/M service:
 
A 9-year-old patient reports to his pediatrician with a 2-cm cut on his forehead and a sore left hand, the result of falling from monkey bars. The physician documents the appropriate history, examines the head wound and performs a neurologic exam related to that injury.  

She also examines the hand and lower arm area for possible fracture or dislocation, determines that there is a sprain of the left hand, and then determines the type of suture needed for the laceration.
 
In this scenario, you have HEM for the laceration and the hand exam, meaning you have a separate E/M.

On the claim:

- report the laceration repair using 12013 (Simple repair of superficial wounds of face, ears, eyelids, nose, lips and/or mucous membranes; 2.6 to 5.0 cm).

- attach 873.42 (Open wound of face, without mention of complication; forehead) to 12013 to account for the forehead wound.

- report the appropriate E/M code. In this case, it would probably be 99212 (Office or other outpatient visit for the evaluation and management of an established patient, which requires at least two of these three key components: a problem-focused history; a problem-focused exam; straightforward medical decision-making), but it could be higher.

- attach modifier 25 to 99212 to show that the physician performed two significant and separate procedures.

- attach 842.10 (Sprains and strains of wrist and hand; hand; unspecified site) to the E/M code to account for the patient's sprained hand.

If you do not report 99212 in this scenario when billing for a Medicare patient, you would miss out on payment of $43.85.

Remember: Although each service has a different ICD-9 code in this scenario, you can file a procedure code and an E/M with the same diagnosis--if the same complaint prompts both services.