Practice Management Alert

Question: I am doing some light coding under the supervision of a senior coder. I was wondering about reporting an evaluation and management (E/M) service with procedures or surgeries I code. If a patient reports for an E/M service and the provider performs an unscheduled procedure or surgery, can I automatically charge for an office E/M if I add modifier 25?

Washington, DC Subscriber

Answer: You should never assume an automatic E/M service, even when the patient reports for an office visit and ends up needing a surgical/procedural service.  If the encounter notes don’t support a separate E/M service, then you should only report the procedure code and leave the E/M off the claim.

Example: A patient reports to the provider for an office visit complaining of an abscess on her torso that “keeps getting bigger.” The provider performs a simple incision and drainage (I&D) on the patient’s abscess and sends the patient home. In this instance, you would definitely report 10060 (Incision and drainage of abscess [e.g., carbuncle, suppurative hidradenitis, cutaneous or subcutaneous abscess, cyst, furuncle, or paronychia]; simple or single) for the encounter.

E/M opportunity: If your physician’s documentation supports a significant, separately identifiable E/M service, you might be able to report an E/M service along with 10060. If you find evidence of an E/M that is not considered part of the inherent service associated with 10060, then you might report:

• 99201-99205 (Office or other outpatient visit for the evaluation and management of a new patient, which requires these 3 key components …) for new patients and
• 99211 (Office or other outpatient visit for the evaluation and management of an established patient, that may not require the presence of a physician or other qualified health care professional … ) or 99212-99215 (Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components …) for established patients.

However, since Correct Coding Initiative (CCI) edits bundle the E/M code with 10060, you will have to append a modifier to allow you to report both codes separately. Since the E/M code is the column 2 code, you will have to 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 to indicate that there was a separate E/M service.

Caution: Do not add a 25 modifier just because the procedure was not scheduled prior to the visit. If the E/M service your physician performed is only the minor E/M typically associated with the procedure, you cannot add modifier 25.

The documentation and medical necessity must demonstrate that the E/M was a significantly, separately identifiable E/M. The fact that the procedure was not scheduled helps but is not an automatic indication to append modifier 25.  Physicians should ask themselves, “Did I really have to evaluate the patient to determine the need for this procedure?” If the answer is yes, then don’t hesitate to bill for the E/M code.

Advice: Document the procedure in the encounter notes, separate from the E/M documentation, and then include E/M documentation that shows a full workup that led to the decision to perform the I&D. These notes could make a big difference when the payer considers whether or not to pay for the E/M service in addition to the I&D.