CODING Q&A Coding Conundrum: E/M with a Procedure ■ DAVID STERN, MD, CPC T he 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 speak- er 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 manage- ment (E/M) in addition to other procedures. Q. A. Ⅲ Ⅲ Ⅲ Ⅲ We always get denials for the E/M code in addition to a procedure. Are we doing something wrong? Denials for payment for an E/M in addition to a proce- dure may stem from several sources: Missing modifier If you perform a procedure with a 0- or 10-day global peri- od 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 addi- tion to certain (rarely all) procedures. Bundling issues Generally, procedure codes include a basic level of eval- uation 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 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.prac- ticevelocity.com), a provider of charting, coding and billing software for urgent care. He may be contacted at dstern@practicevelocity.com. w w w. j u c m . c o m 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. A. What urgent care procedures require modifier -25? 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. A. When is modifier -25 used? 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 neces- sary to aspirate the joint and send the fluid to the lab for analy- sis to help confirm the diagnosis. Code with the E/M with mod- ifier (for example, 99213-25) and 20610 for the knee joint aspiration. Thus, a new problem that requires more than a curso- ry review also, generally, qualifies for an E/M with modifier -25. “Established patients” with additional medical problems JUCM T h e J o u r n a l o f U r g e n t C a r e M e d i c i n e | J a n u a r y 2 0 0 7 35