Primary Care Coding Alert

In an unusual move, HCFA has announced the suspension of national Correct Coding Initiative (CCI) edits that were implemented during the fourth quarter of 2000. The edits bundled 66 evaluation and management (E/M) codes with more than 800 diagnostic tests and procedural services that carry no global surgical period (XXX global days).

When the edits were put into place Oct. 30, 2000, HCFA stipulated that an E/M service would be payable on the same day as the bundled procedures only if it was significant and separately identifiable. Coders were required to append the E/M service with modifier -25 (significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) when submitting the claim.

HCFA has provided no reason for the suspension. However, coding experts believe the agency is responding to physicians and coders who have reported a big increase in denials when they bill E/M services with diagnostic tests like x-rays, spirometry, EKGs and cardiac event monitoring, even when modifier -25 is attached. HCFA has not closed the door on reintroducing the suspended edits, but has made clear its intentions to educate physicians and carriers about the appropriate use of modifier -25 and what constitutes a significant, separately identifiable E/M service.

Edits Were Intended to Prevent Double-dipping

HCFAs apparent determination to pay only for E/M services deemed significant and separate is due, at least in part, to chronic double-dipping by some physicians when diagnostic tests are performed, says Susan Callaway, CPC, CCS-P, an independent coding and reimbursement specialist and educator in North Augusta, S.C. In fact, when it introduced the edits, HCFA stated they were designed to prevent the practice of physicians reporting an E/M service code for the inherent evaluative component of the procedure itself. Because every procedure has an inherent E/M component, for an E/M service to be paid separately, a significant, separately identifiable service would need to be documented in the medical record.

Although HCFA now says that any denied claims involving E/M services and diagnostic tests submitted after Oct. 30 should be resubmitted, it recommends that physicians continue to attach modifier -25 to the E/M service when refiling the claim. In other words, family physicians must demonstrate in the patients medical record that the E/M service was significant and separately identifiable. Presumably, any new E/M services performed with a variety of diagnostic tests and other services with no global days also require modifier -25.

Reporting E/M Services With Modifier -25 Correctly

Family practices may report an E/M service (modified by -25) and expect payment if documentation indicates the visit led to the decision to perform the procedure, according to Christine Schon, FACMPE, senior director of physician practice operations with Bassett Health Care, an integrated delivery system serving the rural population in central and upstate New York.

For instance, a patient may schedule an office visit because she has been experiencing wheezing and shortness of breath while she exercises. The family physician performs a complete workup, including history, examination and medical decision-making. In addition, the doctor conducts a bronchospasm evaluation. In this case, both the spirometry code (94060, bronchospasm evaluation: spirometry as in 94010, before and after bronchodilator [aerosol or parenteral]) and appropriate level E/M code, appended with modifier -25 (i.e., 99213-25), may be reported.

To support the claim, Schon suggests that different diagnosis codes be linked to each of the services provided. For instance, 786.07 (dyspnea and respiratory abnormalities, wheezing) may be linked to the E/M code, while 493.00 (extrinsic asthma, without mention of status asthmaticus) may be linked to the pulmonary function test code.