Primary Care Coding Alert

Question: Do the CMS 2022 guidelines require modifier 25 for an evaluation and management (E/M) cardiology office visit code when billing EKG code 93000?

Connecticut Subscriber

Answer: When you bill 93000 (Electrocardiogram, routine ECG with at least 12 leads; with interpretation and report), remember that the National Correct Coding Initiative (NCCI) says that EKG codes include preprocedure, intraprocedure, and postprocedure work. This means that work typically involved in the provision of an EKG should not be billed separately using, for example, an E/M code.

However, whenever the practitioner performs a significant and separately identifiable E/M service, you may want to use 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) appended to the E/M code. Although there are no NCCI edits that bundle 93000 and a problem-oriented E/M office/outpatient visit other than 99211, some payers may have their own bundling rules in this regard.

For example, if during the EKG visit the patient asks the physician about a concern that is unrelated to the EKG, and the physician documents thoroughly that they performed a separate E/M, including the evaluation of the problem as well as a plan to manage it, that is a scenario that would call for modifier 25 appended to an appropriate level of E/M service.

One important thing to keep in mind — perhaps the reasoning behind the thought that an E/M with 93000 requires modifier 25 in the first place — is that according to Medicare’s National Coverage Determination (NCD) for electrocardiographic services, Section 20.15 (https://www.cms.gov/medicare-coverage-database/view/ncd.aspx?NCDId=179), Medicare won’t cover EKGs when performed as a screening test or as part of a routine exam unless performed as part of the one-time “Welcome to Medicare” preventive physical examination, G0402 (Initial preventive physical examination; face-to-face visit, services limited to new beneficiary during the first 12 months of Medicare enrollment). This means the EKG service will be covered by Medicare only if the test is medically necessary, such as performed for a new clinical reason (not as a preventative measure) or to assess an established condition.

So, if you are reporting 93000 and an E/M service with modifier 25 appended to Medicare, the documentation needs to support the need for the E/M, that the E/M was significant and separately identifiable from the EKG, and that the EKG itself was medically necessary. If the notes aren’t clear, be sure to communicate that with the provider.