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 (12001) with no other injuries to assess, and the physician performs the minor procedure only. In this case, because the visit does not involve significant, identifiable services, you should not separately bill an E/M service.