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DAVID STERN, MD (Practice Velocity)

Q. Can a patient be billed for an E/M code and an ultrasound procedure such as 93970, “Duplex scan of extremity veins including responses to compression and other maneuvers; complete bilateral study” during the same visit when both the scan and the E/M visit were performed by the same provider?

A. If during an office visit it is determined that the ultrasound procedure needs to be performed on the same day as the visit, you may code an E/M in addition to the procedure. You would append modifier -25 to the E/M code.
CPT guidelines do state, however, that if only a hand-held or other Doppler device is used and a hard copy of the results is not produced, then the CPT code for the noninvasive vascular pro- cedure may not be used, because the procedure is deemed to be included in the E/M service.
However, during an outpatient visit, if the provider determines that the patient needs the ultrasound procedure performed but the patient is scheduled for the procedure on a different day, you would not bill an additional office visit on the day the patient re- turns for the procedure.
Be sure to check Local Coverage Determination (LDC) rules with state licensing authorities, and with each payor, because some entities have limitations on who can perform or bill for noninva- sive vascular diagnostic studies. For example, the provider or set- ting for these procedures may be limited to:

  • physicians who are  competent  in diagnostic vascular studies;
  • physicians who are under general supervision by physi- cians who are credentialed in vascular technology;
  • technicians who are certified in vascular technology; or facilities with a laboratory accredited in vascular technology

Q. If during a well child exam a pediatrician discovered the patient had eczema and prescribed treatment, is the treatment of the eczema significant enough to warrant using a modifier -25?

A. Modifier -25, “Significant, separately identifiable evaluation and management service by the same physician or other qualified health care professional on the same day of the procedure or other service” is reserved for E/M codes (i.e., in urgent care, CPT codes 99201-99215) so you would not append it to the well child/preventive service code.
If billing an E/M code, you would not use modifier -25 unless another appropriate billable “procedure or service,” such as a wound repair or a foreign body removal, was performed.

Q. As an employee of a family practice/pediatrics center, I have been asked to add S9088 when a patient comes in on the same day without a scheduled appointment. We are not licensed as an urgent care clinic, but we do see patients who come in without an appointment. Our hours of operation are 8:30 a.m. to 5:00 p.m. Monday through Friday only. Can we use urgent care codes for the patients we treat who do not have an appointment?

A.If you are referring to HCPCS code S9088, “Services provide in an urgent care center,” you should not use this code in a physician office setting because it is specifically reserved for use by urgent care centers.
However, there are a few codes that you might be able to consider using in an office situation. CPT code 99058, “Service(s) provided on an emergency basis in the office, which disrupts other scheduled office services, in addition to basic service,” could be used for someone who did not have a scheduled appointment but was in need of an emergency service and had to be taken back to an exam or procedure room immediately for treatment.
In that instance, you would bill CPT code 99058 in addition to the appropriate E/M code as well as codes for any other procedures performed. However, for urgent care centers, CPT Assistant has made a controversial statement that this code is not appropriate for clinics that typically see patients on a walk-in basis.

Modifier -25 and Urgent Care Codes

David Stern, MD

Chief Executive Officer at Experity, Previous Chief Executive Offer at Practice Velocity Urgent Care Solutions, Founding Member of the Urgent Care Association of America, Publishing Staff for The Journal of Urgent Care Medicine