We have a situation where our ENT provider evaluated a patient, the intent of the visit was to follow up on the patient's dizziness. During the course of the evaluation he made a treatment decision to provide a decadron injection within the ear (CPT 69801) thus completing his treatment plan. Then he proceded to carry out the procedure (instead of bringing the patient back on another day). He provided 99214-25 with a dx code of 386.00 Meniere's Disease and provided CPT 69801 with a dx code of 386.8 Cochlear-Labyrinthine Disorder. The carrier paid the injection but is denying his E/M stating a modifier 25 situation is not present.
According to 2013 CPT guidelines for Modifier 25: It may be necessary to indicate that on the day a procedure or service identified by a CPT code was performed, .....or beyond the usual preoperative and postoperative care associated with the procedure that was performed. .....The E/M service may be prompted by the symptom or condition for which the procedure and/or service was provided. As such, different diagnoses are not required for reporting of the E/M service on the same date. (my emphasis being on the first few statements, since the provider did give two separate dx codes).
I also have an old "Coding Corner" article from an AAPC member that states: The AMA guidelines, as outlined in the CPT codebook and CPT Assistant, also clearly and consistently support coding for a "minor" procedure and a separate, significant same-day E/M with modifier 25. Later it states ....."All services and procedures include an "inherent" E/M component. A brief history and physical prior to a same-day scheduled outpatient procedure are included componetns of the procedure itself. (my emphasis on the procedure being scheduled).
When I pulled our local MCR policy, it appears that our MCR carrier would side with Optima according to their examples but here are my question(s):
1. Have the carrier(s) blurred the true meaning behind the CPT language? or I'm I confusing it? To me it allows room for an E/M to be billed when the E/M was the "intent" of the visit and the "procedure" was not scheduled but a consequence of the visit. I totally agree that if the injection had been the "intent" of the visit; then no E/M should be allowed but in this case you have a provider who has separately evaluated the patient for dizziness and then provided a treatment option for the condition same day.
Seems to me that we have lost the prespective of whether the procedure was "scheduled" or not. If carriers are taking this out of the equation than they can totally reverse any E/M that is performed the same day as a procedure.
2. Does the scheduling of the procedure make a difference in the use of Modifier 25? (the older but not out-of-date literature I have indicates yes).
3. Does the fact that the procedure has a zero day global period make a difference one way or another? (this would make it a 'minor' procedure')
Thank you so much for any information, help, or references you may have! elaine lankford
According to 2013 CPT guidelines for Modifier 25: It may be necessary to indicate that on the day a procedure or service identified by a CPT code was performed, .....or beyond the usual preoperative and postoperative care associated with the procedure that was performed. .....The E/M service may be prompted by the symptom or condition for which the procedure and/or service was provided. As such, different diagnoses are not required for reporting of the E/M service on the same date. (my emphasis being on the first few statements, since the provider did give two separate dx codes).
I also have an old "Coding Corner" article from an AAPC member that states: The AMA guidelines, as outlined in the CPT codebook and CPT Assistant, also clearly and consistently support coding for a "minor" procedure and a separate, significant same-day E/M with modifier 25. Later it states ....."All services and procedures include an "inherent" E/M component. A brief history and physical prior to a same-day scheduled outpatient procedure are included componetns of the procedure itself. (my emphasis on the procedure being scheduled).
When I pulled our local MCR policy, it appears that our MCR carrier would side with Optima according to their examples but here are my question(s):
1. Have the carrier(s) blurred the true meaning behind the CPT language? or I'm I confusing it? To me it allows room for an E/M to be billed when the E/M was the "intent" of the visit and the "procedure" was not scheduled but a consequence of the visit. I totally agree that if the injection had been the "intent" of the visit; then no E/M should be allowed but in this case you have a provider who has separately evaluated the patient for dizziness and then provided a treatment option for the condition same day.
Seems to me that we have lost the prespective of whether the procedure was "scheduled" or not. If carriers are taking this out of the equation than they can totally reverse any E/M that is performed the same day as a procedure.
2. Does the scheduling of the procedure make a difference in the use of Modifier 25? (the older but not out-of-date literature I have indicates yes).
3. Does the fact that the procedure has a zero day global period make a difference one way or another? (this would make it a 'minor' procedure')
Thank you so much for any information, help, or references you may have! elaine lankford
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