Urology Coding Alert

Question: In the introduction to Correct Coding Initiative (CCI ) version 13.3 and the subsequent versions (including the most recent, 14.1), it says, "... a significant and separately identifiable E/M service unrelated to the decision to perform the minor surgical procedure is separately reportable with modifier 25." But in some cases, our urologist must perform a service for a related procedure during the same visit. Is the modifier no longer applicable for these services?

New Jersey Subscriber

Answer: The new language has been confusing for quite a few practices, but Medicare lays your fears to rest with specific guidance on this topic.

CMS "does not require that the significant and separately identifiable E/M service and the minor surgical procedure be reported with different ICD-9 codes," a CMS spokesman told The Coding Institute. "Both may be related to the same medical problem."

The spokesman points to the following citation from chapter 12, section 40.1, of the Medicare Claims Processing Manual: "Visits by the same physician on the same day as a minor surgery or endoscopy are included in the payment for the procedure, unless a significant, separately identifiable service is also performed. For example, a visit on the same day could be properly billed in addition to suturing a scalp wound if a full neurological examination is made for a patient with head trauma. Billing for a visit would not be appropriate if the physician only identified the need for sutures and confirmed allergy and immunization status."

Therefore, if the urologist performs an E/M service and a procedure on the same date, you can continue to append modifier 25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) to the E/M code, as long as the physician's documentation meets the requirements of the codes and the modifiers on the claim.

Remember: To ensure reimbursements for both the E/M service and pro-cedure, the documentation of the exam and operative report should be on separate sheets or different places within the medical records to indicate the separate nature of the services.

-- Answers to Reader Questions and You Be the Coder contributed by Michael A. Ferragamo, MD, FACS, clinical assistant professor of urology, State University of New York, Stony Brook.