Psychiatry Coding & Reimbursement Alert

Hint: Codes can be unbundled by using suitable modifier.

Exercise caution if you are planning on reporting two E/M codes for the same patient on the same calendar date of service. The latest version 20.2 of the Correct Coding Initiative (CCI) edits that came into effect on July 1, 2014, includes new edit bundles that do not allow you to report these services together. 

Summary: In CCI 20.2, effective July 1, 2014, there are 20,729 new edit pairs. While there are only 212 terminations, there’s a net gain of 20,517 new edit pairs for a total of 1,334,994 active edit pairs in the database. There are 107 changes to the modifier indicator, and of these, 90% went from 1 (you can use a modifier if appropriate) to 0.

Always Check CCI Before Reporting Two E/M Services on Same Calendar Date of Service

Although you will usually report only one E/M code for a patient visit on one calendar date of service, you may encounter instances when you will have to report more than one E/M code for the same patient on the same calendar date of service.

As stated in section 30.6.5 of chapter 12 of the Centers for Medicare and Medicaid Services (CMS) Medicare Claims Processing Manual, “Physicians in the same group practice who are in the same specialty must bill and be paid as though they were a single physician. If more than one evaluation and management (face-to-face) service is provided on the same day to the same patient by the same physician or more than one physician in the same specialty in the same group, only one evaluation and management service may be reported unless the evaluation and management services are for unrelated problems.”

So, if your psychiatrist or two of your physicians evaluate the patient twice (typically at different times) on the same calendar date service for unrelated problems, you may report two E/M codes for the two distinct encounters. The version 20.2 of the CCI edits bundles office/outpatient new patient E/M codes (99201-99205) with established patient codes (99211-99215). Also, lower level established patient codes are bundled into a higher level established patient code.

For example, a level two established patient code (99212) is bundled into a level two new patient code (99202) and other new patient office/outpatient E/M codes. Another example of this bundling between established patient codes is a level three established patient code (99213) being bundled into a level four or level five established patient code (99214 or 99215).

Modifier indicator: Even though you face edits when trying to report two office visit E/M codes for a patient on the same calendar date of service, you can report both the codes for the patient separately. You are permitted to do this because the modifier indicator for the above mentioned code bundles is ‘1,’ which means you can unbundle the codes by using a modifier. The modifier that you will have to use with the column 2 code is 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).