Wiki Separately identifiable E/M

[johncyrose]

There seems to be a lot of ambiguity in defining separately identifiable E/M services. We have scenarios where patients were referred to different specialtists (Cardiology, ENT, GI, etc) who come and evaluate the patient. They eventually decide that the pt will have to undergo a procedure (Heart Cath, mandibular sx, EGd, etc) which happened to be completed on same DOS. We would add the appropriate -25 or -57 modifier. These used to be paid but recently we've been getting denials for the E/M, even with appropriate modifier appended. I guess my question is how do you really determine that the E/M is separately reportable when the provider would have to see the pt for the consult before they can decide if certain procedures are clinically indicated or not.

 

[csperoni]

I do not necessarily agree with the above answer. If you are evaluating the patient and determine that a surgery is necessary, then -57 is totally appropriate. I find often commercial insurance will deny and we need to appeal with the records and explain -57 modifier.
The full description is Decision for Surgery: An evaluation and management service that resulted in the initial decision to perform the surgery may be identified by adding modifier 57 to the appropriate level of E/M service.
For modifier -25, it does not need to be a separate condition. That would be an ideal example, but it can be the same condition. It simply needs to be above and beyond the usual pre-op care. They may be managing medications, determining treatment course, etc. A 2 sentence note of "abnormal EKG and chest pain x2 days. pt needs cath." is obviously not going to meet -25. What I do is look at the note and eliminate the portions that would typically be the preop evaluation. Is what remains enough to justify a visit? If yes, then -25 is appropriate and should be appealed if denied. It is most typically (but not always) appropriate for new patients or patients with a new or worsening problem.

Remember that just because the insurance does not want to pay does not mean they are correct.

This is a good AAPC article about -25. https://www.aapc.com/blog/24044-five-for-modifier-25/