Primary Care Coding Alert

The answer to your question gives 'yes' or 'no' to modifier 25.

If your family physician performs an E/M service and a procedure on the same patient during the same encounter, you might be able to report the E/M using modifier 25 (Significant, separately identifiable E/M service by the same physician on the same day of the procedure or other service). Or you might not.

The key: You must prove that the E/M is a separate service and is not a built-in component of the procedure. Remember two things to determine when to report an E/M with modifier 25, and when to leave the E/M off the claim.

Uncover E/M Evidence in Notes

"Coders should use modifier 25 when a significant, separately identifiable E/M service is performed by the same physician at the same face-to-face encounter as a procedure or other service," says Catherine Brink, CMM, CPC, president of Healthcare Resource Management of Spring Lake, N.J.

The most vital element on successful modifier 25 claims is concrete evidence that the procedure and E/M service were truly separate, Brink says. All procedure codes have an inherent E/M component built into them, and the physician must go beyond that to justify a separate E/M. In addition, the E/M service must also meet medical necessity criteria. If it doesn't, you should just report the procedure code.

Tip 1: Ask your physicians to separate documentation of the E/M service from the procedure note so it's easier for you to spot the necessary information.

Tip 2: Check that the necessary elements of the E/M service are all present and accounted for in your physician's documentation. Ask yourself whether the documentation supports the level of history, exam, and medical decision making being claimed with the E/M code being billed in addition to the procedure code.

Watch for Exam That's Beyond 'Limited'

Now check out this scenario in which the physician performs a procedure and a separate E/M service: A new patient presents with dull aching pain in his jaw. The pain has persisted for three weeks, and despite taking Motrin for the pain, he's gotten no relief. The patient is a teacher, andhe says the pain gets worse after he teaches classes all day. Your physician performs a review of systems; past, family  and social history; an expanded problem-focused history and an expanded problem-focused exam on the jaw, including a check for tenderness, swelling, popping/clicking or difficulty moving. He makes an initial diagnosis of temporomandibular joint disorder but orders follow-up tests as confirmation. In the meantime, he administers a trigger point injection to relieve the patient's immediate pain.

Code it: In this instance, the physician performed a significant E/M service before deciding to administer the injection. On the claim, therefore, you should report the following:

• 20552 (Injection[s]; single or multiple trigger point[s], one or two muscle[s]) for the injection
• 99202 (Office or other outpatient visit for the evaluation and management of a new patient, which requires these three key components: an expanded problem-focused history; an expanded problem-focused examination; straightforward medical decision-making) for the E/M service
• Modifier 25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) appended to 99202 to show that the injection and the E/M were separate services
• The most appropriate diagnosis from 524.6x (Temporomandibular joint disorders).