Coding Conundrum: E/M with a
Procedure
David Stern, MD, CPC
The urgent care practitioner may not live by coding alone, but
proper reimbursement depends on it. To that end, Dr. David
Stern, a certified coder who is in great demand as a speaker
and consultant on coding in urgent care, will offer answers
to commonly asked questions in every issue of JUCM.
In this issue: proper coding for evaluation and management
(E/M) in addition to other procedures.
Q. We always get denials for the E/M code in addition
to a procedure. Are we doing something wrong?
A. Denials for payment for an E/M in addition to a procedure
may stem from several sources:
Missing modifier
If you perform a procedure with a 0- or 10-day global period
and you perform and document a separate E/M on the
same day, always attach modifier -25 to the E/M to
reduce denials and costs of rebilling. Use modifier -57 for
an E/M performed on the same day as a procedure with
a 90-day global period.
Payor policy
Some payors routinely deny payment for an E/M in addition
to certain (rarely all) procedures.
Bundling issues
Generally, procedure codes include a basic level of evaluation
of management within the procedure code. In
the urgent care setting, however, bundling the E/M into
the procedure code is frequently not appropriate.
Lack of supporting documentation
Some payors automatically deny an E/M in addition to a
procedure, or at least in addition to a certain procedure. For
example, some payors deny payment for an E/M when
billed in a claim along with a code for ear wax removal.
Even in these cases, however, payment might be obtained
by submitting proper documentation.
Q. What urgent care procedures require modifier -25?
A. In general, all procedures with a 10-day global period
(and many others with a 0-day global period) should
have modifier -25 attached to the E/M code.
Q. When is modifier -25 used?
A. Per the AMA definition, modifier -25 should be used
when a “significant, separately identifiable E/M service
above and beyond the other service provided or beyond the
usual preoperative and postoperative care associated with the
procedure that was performed” is required. The interpretation
of this rule is sometimes difficult and there are a few gray
areas where not all coders or payors agree. For example:
Patients who are new to a practice The initial E/M (99201-
99205) for a new patient who also has a minor procedure (0-
to 10-day global period) performed on the same day should not
require the -25 modifier on the E/M code. This makes sense, as
the patient is not known to the provider and all of the baseline
history, medications and basic health status must be determined
prior to doing the “usual preoperative care.”
New problems that require significant evaluation beyond the
procedure For example, a patient may present with knee pain.
After evaluation of the knee, the physician determines that the
problem may be gout or infectious arthritis, and that it is necessary
to aspirate the joint and send the fluid to the lab for analysis
to help confirm the diagnosis. Code with the E/M with modifier
(for example, 99213-25) and 20610 for the knee joint
aspiration. Thus, a new problem that requires more than a cursory
review also, generally, qualifies for an E/M with modifier -25.
“Established patients” with additional medical problems Patients undergoing a procedure that is made more complicated
because of an underlying medical problem should have
that problem evaluated and managed appropriately. Take, for
example, a patient who presents with an abscess and who also
suffers from AIDS, diabetes, valvular heart disease, or elevated
blood pressure. In this case, the physician should document evaluation
and management of both the problem that is addressed
by the procedure and the E/M of the complicating problem. An
E/M with modifier -25 is always appropriate in addition to the
code for the procedure.
"Established patients" with a second medical problem that
requires attention An E/M is always appropriate for patients
receiving evaluation and management services for diagnoses
in addition to the problem necessitating the procedure. For
example, a patient may present with a laceration, but in the
course of evaluation and management the physician determines
that the patient has also been suffering from chronic diarrhea.
The physician begins the work-up by ordering collection
of a stool specimen for culture and microscopic examination
for ova and parasites. The laceration code and the E/M code
with modifier -25 should be used.
"Established patients" seen in the urgent care setting A typical
urgent care center is quite different from a typical
physician office. In the urgent care center, very few patients
are truly established with the provider who is providing
the services. Essentially, these are new patients who truly
need a thorough history and physical prior to the initiation
of the usual preoperative care. Thus, in the urgent care
center a full history and physical are almost always required
to evaluate the past medical history, medications, and current
symptoms prior to initiating the usual preoperative
care that would be provided to a patient who was truly
established and, thus, well known to the provider.
It is one thing for Dr. Welby to walk in the room and say, "Oh,
Johnny, so you cut your finger again. You need to be more careful
with your whittling knife. Don't worry, we'll sew that up in
a jiffy. Since you don' have any other problems except for that
heart murmur, you should do great."
It is another matter entirely for Dr. Urgentowitz to see the
same patient, and inquire about diabetes, history of infections,
the relevance of the heart murmur, and the patient's experience
with previous injuries. Then the urgent care doctor
examines the patient's skin, eyes, heart, lungs, and peripheral
vasculature to evaluate the status of any known conditions and
to see if there are any additional underlying or complicating
medical conditions.
Generally, a separate E/M is appropriate for patients seen in
the urgent care center. Of course, if the urgent care physician
also functions as the primary care provider for the patient, the
patient is truly established with the practice and an additional
E/M is often not appropriate.
Q. Must I have a separate diagnosis to code
modifier -25?
A. One myth that seems to have a life of its own is that the
patient must have a "significant separately identifiable"
problem that is managed on this visit. But the AMA definition
of modifier -25 clearly states:
"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 services
on the same date."
The problem and confusion arises, however, when overzealous
payors (in direct contradiction of AMA guidelines) require
physicians to treat a second condition before they will consider
payment for an E/M with modifier -25. It is the E/M note, not
a second presenting problem, which must be "significant and
separately identifiable." Nonetheless, several large payors continue
to apply the tightfisted requirement that the physician
must supply both documentation of a second diagnosis and
medical records supporting separate E/M services for that
second diagnosis.
Q. Will attaching modifier -25 to an E/M where the
modifier was not required trigger a denial?
A. No, payors almost never deny payment for attaching
modifier -25 to an E/M code where the modifier was not
required. Be careful to use modifier -25 only when a procedure
is performed, as overuse of the modifier may trigger a payor
audit.
Q. I was audited and the carrier denied payment
because of inadequate documentation. Do I simply need a longer visit note?
A. It is not the length, but the content of the visit record
that is important. In order to support both an E/M
code and a procedure code, the patient record must contain
documentation of the level of evaluation and management
AND a significant, separately identifiable procedure note. It is
best to not include the procedure note within the evaluation
and management note, as some auditors will deny the code
because the procedure note was not "separately identifiable"
from the evaluation and management documented in the
patient record. Some coders go so far as to recommend a
separate page, template, or dictation for each E/M and
each procedure note.
Note: CPT codes, descriptions, and other data only are copyright 2007 American Medical Association. All Rights Reserved (or such other date of publication of CPT). CPT is a trademark of the American Medical Association (AMA).
Disclaimer: JUCM and the author provide this information for educational purposes only. The reader should not make any application of this information without consulting with the particular payors in question and/or obtaining appropriate legal advice.
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David Stern is a partner in Physicians Immediate Care, with nine urgent care centers in Illinois and Oklahoma, and chief executive officer of Practice Velocity (www.practicevelocity.com), a provider of charting, coding and billing software for urgent care. He may be contacted at
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