You should also know that an ekg (93000) doesn't bundle to outpatient/office E/M's, so no modifier is required to report them together. 94010 does, though.
To know when to use the 25 modifier, you need to be able to tell when an E/M is considered "significant and separately identifiable". It's not as hard to spot as it seems...When a patient comes in, there's a reason (obviously
). If that reason is to receive some sort of treatment
that's already been determined (like a shot, or to have labs or other diagnostic procedures done), then it wouldn't be appropriate to bill a separate E/M.
But, if the patient has a problem that the provider has to evaluate/assess, decide how to treat it, and then carry out a treatment plan, you now have an E/M service that's reportable. Using the example you provided: if a patient comes in with chest pain and SOB, the doctor doesn't necessarily
know that the cause is related to their heart. He has to perform the EKG to confirm or rule-out a
suspected heart condition, but the EKG alone will not determine the diagnosis, and it certainly won't formulate a treatment plan. Although it contributes to the evaluation/management process, the EKG doesn't convey the amount of work the doctor did.
Another example would be, when a patient comes in with an acute condition, like bronchitis, and requires an antibiotic injection. The E/M will bundle to the injection administration (96372), without a modifier. If the provider evaluated the patient's condition during the visit, and decided that the injection would be the best course of treatment for the problem, then you can bill the office visit separately. But, if a patient already has a treatment plan established that doesn't need to be re-evaluated at the time of service, then you shouldn't bill an E/M with it. An example of this would be for male patients that receive regular testosterone injections - they may come in every 2 weeks for injections, but it would only be appropriate to bill an E/M once every few months, as needed to make sure that the injections are working effectively.
When you're trying to decide if you can bill services for E/M separately, keep these things in mind:
1. If something's going to bundle to something else, it's probably going to be the E/M that denies. It's rare to see services that are incidental to E/M services (except in critical care). Most of the time, you have to prove that the assessment of the patient went further than is normally required to perform a procedure, which is the whole purpose of the 25 modifier.
2. Was it
necessary for the
doctor to examine the patient during the visit?
3. Did the doctor make a new decision about the patient's treatment (including keeping the same treatment plan, if it's working), or had he already figured out what needed to be done during a previous encounter?
If you can answer "yes" to both #'s 2 & 3, you should be able to bill a separate E/M with confidence.
Hope that helps!
