(Keeping Specialists Compliant continued) alone to justify reporting an e&m service on the same date of service as a minor surgical procedure. The CCI manual gives the example of a patient who is being seen for a head laceration. The physician who repairs the laceration should not report an e&m code if the interaction with the patient involves simply checking allergy and immunization status and obtaining informed consent. However, the physician can report an e&m code with modifier 25 if they perform a “medically reasonable and necessary full neurological examination” in addition to the wound repair. according to the march 2012 issue of the american medical association’s newsletter “CPT assistant,” the e&m service “is generally unrelated to the procedure or service being provided but may, on occasion, be prompted by the symptom or condition for which the procedure and/or service was provided.” 2 Nonsurgical procedures (those with a global indicator of “XXX”) do not have a global period. a good example of a nonsurgical procedure is radiological exams performed in a specialist’s office (e.g., an ultrasound performed at an ob-gyn). However, an e&m code should be reported together with a nonsurgical procedure only if there was a significant, separately identifiable e&m service in addition to the procedure. The CCI manual states the following: many of these “XXX” procedures are performed by physicians and have inherent preprocedure, intraprocedure, and postprocedure work usually performed each time the procedure is completed. This work should never be reported as a separate e&m code. Other “XXX” procedures are not usually performed by a physician and have no physician work relative value units associated with them. a physician should never report a separate code with these procedures for the supervision of others performing the procedure or for the interpretation of the procedure. With most “XXX” procedures, the physician may, however, perform a significant and separately identifiable e&m service on the same date of service which may be reported by appending modifier 25 to the e&m code. This e&m service may be related to the same diagnosis necessitating performance of the “XXX” procedure but cannot include any work inherent in the “XXX” procedure, supervision of others performing the “XXX” procedure, or time for interpreting the result of the “XXX” procedure. appending modifier 25 to a significant, separately identifiable e&m service when performed on the same date of service as an “XXX” procedure is correct coding. as previously stated, a significant and separately identifiable e&m service unrelated to the decision to perform the minor surgical procedure is separately reportable with modifier 25. In a 2005 audit report (“use of modifier 25,” OeI-07-03-00470), 36 HBma BIllINg • maY. juNe.2014 the OIg found that 35 percent of modifier 25 claims that were allowed by medicare in 2002 did not meet the requirements for payment, resulting in $538 million in improper payments. This finding highlights the widespread problems with documentation and coding of e&m services performed in conjunction with procedures. modifier 25 should be appended to the e&m service if the patient’s condition requires a significant, separately identifiable e&m service on the same day as a surgical (invasive diagnostic) procedure. The e&m service must be greater than the pre- or postservice work for the procedure. The e&m note should be distinct from the procedure note. It is not necessary to generate two separate documents, but the physician should at least document the two services in separate paragraphs. also, the e&m service must meet all the documentation criteria for a billable service. If the encounter involved the decision to perform a minor procedure, then part of the assessment and plan will include documentation of that decision. Both the american medical association (ama) and Centers for medicare & medicaid services (Cms) have stated that a different diagnosis is not necessary when billing an e&m service and a procedure on the same day. However, in the same vein, it is inappropriate to bill for an e&m service every time the patient is seen for a planned procedure. also, keep in mind that despite the ama and Cms guidance, some third-party payors are not paying for these services unless the procedure and the e&m service are reported with different diagnoses. This is an important area to be scrupulous about for your clients. If there is always an e&m service billed on the same day as a procedure, view this as a red flag and investigate. regardless of your role in the coding process, you want to serve as a valued business partner for your clients. There is a roll-down effect for coding and compliance. If your client has compliance challenges, they could potentially impact their practice, their cash flow, and their contractual relationship with you. Melody W. Mulaik, MSHS, is the president and co-founder of Coding Strategies, Inc. and Coding Metrix, Inc. located in Atlanta, Georgia. She is a frequent speaker and author for CSI and other nationally recognized professional organizations and publications. Melody's areas of expertise include billing and collections, coding and compliance, revenue enhancement, front-end hospital operations, management engineering, medical school relations, and operations improvement. Resources 1 http://oig.hhs.gov/reports-and-publications/archives/ workplan/2014/Work-Plan-2014.pdf - page 17 2 http://www.cms.gov/medicare/Coding/NationalCorrectCod
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