Primary Care Coding Alert

Question: Payers always deny starred procedures when billed with an E/M code and modifier -25. Our biller writes off the office visit. Shouldn't we go after this money?

Kansas Subscriber
Answer: Before writing off the E/M service, make sure the claims support separately reporting the office visit, such as 99211-99215 (Office or other outpatient visit for the evaluation and management of an established patient ). For you to bill 99211-99215 appended with modifier -25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service), the office visit must be a significant, separately identifiable E/M service from the minor procedure, according to CPT. Look over your denials and appeal any that have different diagnoses or significant E/Ms, as the following two examples demonstrate.

Separate diagnoses although unnecessary for the office visit and starred procedure signal that both the E/M service and the procedure are separately reportable.

For instance, your FP evaluates (99211-99215) a patient for hypertension (such as 401.1, Essential hypertension; benign) and also cauterizes a problematic lesion (for example, 17000*, Destruction [e.g., laser surgery, electrosurgery, cryosurgery, chemosurgery, surgical curettement], all benign or malignant lesions [e.g., actinic keratoses] other than skin tags or cutaneous vascular proliferative lesions; first lesion; 078.19, Viral warts; other specified viral warts) during the same visit. Because a different reason exists for the office visit (401.1) than for the starred procedure (078.19), you should separately report the E/M service (99211-99215-25) and appeal any denials.

But if the FP performs a significant E/M service and a minor procedure, even if the diagnosis is the same, report both the visit and the procedure. For instance, a mother brings in her child who has fallen off his bike. The physician examines the patient for a closed head injury, which is unfound, and repairs a simple head laceration measuring 0.5 cm (12001*, Simple repair of superficial wounds of scalp, neck, axillae, external genitalia, trunk and/or extremities [including hands and feet]; 2.5 cm or less). The E/M for the head injury represents a significant, separately identifiable E/M service from that involved in closing the wound. Therefore, you should report the service (99211-99215) appended with modifier -25, and the procedure (12001). If the payer rejects the E/M code, appeal the denial unless your office is sure that after numerous appeals a given carrier will never pay for the service.

That being said, you should be realistic about the significance of an office visit for a minor procedure. Suppose a patient presents for a simple procedure only, such as lesion removal (17000) or wound treatment [...]