PROFESSIONAL BILLING COMPLIANCE TRAINING PROGRAM MODULE 2 EVALUATION AND MANAGEMENT (E/M) SERVICES

Transcription

1 PROFESSIONAL BILLING COMPLIANCE TRAINING PROGRAM MODULE 2 EVALUATION AND MANAGEMENT (E/M) SERVICES

2 Evaluation and Management (E/M) Documentation E/M Documentation Background: Physician payment for inpatient and outpatient clinical visits and consults are E/M codes that are derived from medical documentation. A pathway that translates physician patient care work into claims and reimbursement mechanisms. Ensures correct payments. Supports correct E/M code level that provides validation for medical review. 2

3 Key Components of E/M 7 Components of E/M Services: 1. History 2. Physical Examination 3. Medical Decision Making 4. Time 5. Counseling 6. Coordination of Care 7. Nature of Presenting Problem Key components The first three components, History, Physical Examination and Medical Decision Making are the key components in selecting the level of E/M services. 3

4 Three Key Components The chart below provides an example of how the three key components (History, Examination and Medical Decision Making) are used in selecting the levels of E/M new patient services. Inpatient New Patient Visit History Examination Medical Decision Making Problem Focused History Problem Focused Examination Straightforward Expanded Focused History Expanded Problem Focused Examination Straightforward Detailed History Detailed Examination Low Complexity Comprehensive History Comprehensive Examination Comprehensive History Comprehensive Examination Moderate Complexity High Complexity 4

5 Key Components of E/M Breakdown: Three key components - History, Examination and Medical Decision Making including the elements in each component. 5

6 E/M Key Component - History History levels are determined by the following: 1. Chief Compliant (CC) 2. History of Present Illness (HPI) 3. Review of Systems (ROS) 4. Past, Family, and/or Social History (PFSH) The extent of the history is dependent upon clinical judgment and on the nature of the presenting problem (s). 6

7 E/M Key Component History (continuation) First Part Chief Complaint: A concise statement describing the symptoms, problem, condition, diagnosis, or other factors as the reason for the encounter. Normally first notation in record. Examples: Pain, shortness of breath, fever. Management of diabetes & HTN, follow-up visit for dizziness. Annual physical exam.* * Preventative services may not be covered by certain payors. 7

8 E/M Key Component History (continuation) Second Part History of Present Illness (HPI): Chronological description of the development of the patient s illness from the 1 st sign and/or symptom to the present. Current E/M guidelines identify 8 elements used to provide further elaboration about the patient s condition. 8

9 HPI: 8 Elements Location: Where is the pain/problem? (abdomen, chest) Quality: Describe the pain/problem? (sharp, dull) Severity: How severe is the pain /problem? (slight) Duration: How long have you had this pain/problem? When did it start? (Two weeks, started after I returned from my trip abroad) Timing: Does this pain/problem occur at a specific time? (one hour after eating) 9

10 HPI: 8 Elements (continuation) Context: Where were you at the onset of this pain/problem? (when walking, after smoking) Modifying Factors: What makes the pain/problem worse or better? (improves when lying down, worse after eating) Associated Signs/Symptoms: What other associated problems are present? (nausea and vomiting, rash, leg swelling) 10

11 Two Levels of HPI Brief = 1-3 elements described Extended = 4 or more elements described, or status of at least 3 chronic or inactive conditions Example of HPI with 5 elements: Duration Quality Location Mr. Doe has for two weeks felt a sharp pain in his left shoulder when he raises his arm. He states that aspirin does not relieve the Context pain. Modifying 11

12 E/M Assessment Question 1 True or False: The following scenario contains 6 HPI elements. Irritating abdominal pain in the right upper quadrant since last night with some nausea prior to the onset of pain. 12

13 E/M Assessment - Answer The answer is False. There are only 4 HPI elements in this scenario. 1. Location Right upper quadrant of abdomen 2. Quality Irritating 3. Duration Since last night 4. Associated signs or symptoms Nausea prior 13

14 E/M Key Component - History Third Part of History - Review of Systems (ROS): An inventory of body systems obtained through a series of questions seeking to identify signs and/or symptoms which the patient has or has had. ROS includes 14 systems. Constitutional symptoms (e.g. fever, weight loss) Eyes Ears, Nose, Mouth, Throat Cardiovascular Respiratory Gastrointestinal Genitourinary Musculoskeletal Integumentary (including breasts) Neurological Psychiatric Endocrine Hematologic/Lymphatic Allergic/Immunologic 14

15 E/M Key Component History (continuation) Third Part of History ROS: Examples of documentation for complete ROS: Patient s ROS is positive for fever and chills, nausea and vomiting. Other 12 systems are negative. Full ROS performed, all 14 systems are negative. Fourteen system review performed; all systems are negative, except as documented above. (This implies that the positive systems were documented in the subjective or in the HPI sections). Complete ROS performed; non-contributory. 15

16 E/M Key Component History (continuation) Third Part of History ROS: Unacceptable examples for documentation of a Complete ROS: All systems reviewed are negative. (Not clear what systems reviewed) ROS is unremarkable ROS is non-contributory 16

17 Three Levels of ROS Problem Pertinent (1 system) Directly related to the problem(s) identified in the HPI (rash Integumentary) Extended (2-9 systems) Directly related to the problem(s) identified in the HPI (rash Integumentary) and a limited number of additional systems (joint pain Musculoskeletal) Complete (at least 10 systems) See example next slide Medi-Cal requires all 14 systems May be completed by patient, nurse or other staff (see slide 30) Pertinent positives and negatives must be referred to in the note 17

18 Three Levels of ROS (continuation) Example of a complete ROS (defined as review of at least 10 systems)*: Patient seen in physician s office with flu-like symptoms. For the past two days she has had chills, fever, and muscle aches. She feels worse in the evening. Her illness is so severe she has not been able to work. She has lost 7 pounds in the last month. She denies abdominal pain, diarrhea, and vomiting. Other 12 systems negative. Constitutional chills, fever, muscle aches Gastrointestinal abdominal pain, etc Other 12 systems are negative gives provider credit for a Complete ROS * MediCal requires 14 ROS for Complete History. 18

19 E/M Assessment Question 2 The ROS is an integral element in which E/M component? a. History b. Exam c. Medical Decision Making d. Counseling 19

20 E/M Assessment - Answer The answer is a. The History component consists of: Chief Complaint HPI (History of Present Illness) ROS (Review of Systems) PFSH (Past Medical, Family, Social History) 20

21 E/M Key Component - History Fourth Part - Past Medical, Family & Social History (PFSH): Consists of a review of one or more of the following three areas: - Past Medical History (P) - Family History (F) - Social History (S) Considered to be interval history for subsequent inpatient visits. May be documented by ancillary staff or by patient but physician must review, date and sign. Non-contributory alone is not sufficient for billing purposes. 21

22 E/M Key Component History (continuation) Fourth Part of History - PFSH Past Medical Current medications Prior Illnesses/injuries Dietary status Operations/hospitalizations Allergies Past Medical Health status or cause of death of siblings/parents Hereditary/high risk diseases Diseases related to the chief complaint, HPI, ROS Social Living arrangements Marital status Drug or tobacco use Occupational/educational history 22

23 Two Levels of PFSH Pertinent: one specific item from any of the three areas (Past Medical, Family, Social) Complete: document specific item from all the three areas For established patients: two of three areas is sufficient for a Complete level of PFSH For consultations: All three areas are necessary. 23

24 Two Levels of PFSH (continuation) Fourth Part of History PFSH: To be non-contributory a statement is required in the documentation to qualify it for a Complete PFSH. Example: Reviewed PFSH, non-contributory to current condition. For those categories of E/M services that require only a followup/interval history, it is not necessary to record information about PFSH (subsequent hospital care and nursing facility care) 24

25 Four Levels of History Component Levels of E/M Services are based on 4 levels of History: Problem Focused (PF) CC, Brief HPI, No ROS, No PFSH Expanded Problem Focused CC, Brief HPI, Pertinent ROS, no PFSH Detailed CC, Extended HPI and ROS, Pertinent PFSH (1) element Comprehensive CC, Extended HPI, Complete ROS and PFSH (3) elements (2 for established patient) 25

26 Four Levels of History Components (continuation) Example of a detailed level of history (CC, Extended HPI and ROS, Pertinent PFSH (1) element): Chief Complaint (CC) - cough HPI Extended (4 elements severe productive cough, increase on exertion, fever, not relieved by OTC medication) ROS Extended (2-9 systems respiratory, constitutional, other 12 systems negative) PFSH Pertinent (1 area smoker) (See table next slide) 26

27 Four Levels of History Requirements 27

28 E/M Assessment Question 3 A comprehensive history consists of: a. 4 HPI elements or status of 3 chronic conditions b. 10 ROS for non-medi-cal cases c. 14 ROS for Medi-Cal cases d. Complete PFSH (three areas for new or initial patients and two areas for established patients) e. All of the above 28

29 E/M Assessment - Answer The answer is (e) all of the above: A comprehensive level of history consists of: Extended level of HPI (4 or more elements or status of 3 chronic or inactive conditions) Complete ROS (10 for non-medi-cal cases and 14 for Medi-Cal cases) Complete PFSH (three areas for new or initial patients and two areas for established patients) 29

30 Patient Questionnaires Patient questionnaires may be used for ROS and the PFSH. ROS may be documented by ancillary staff or by patient. However, questionnaire must be referenced in the attending physician s or NPP s note and signed by the provider. If patient unable to give history, document reason patient is unable to respond - Example: Patient unconscious, intubated, poor historian - Example: Unable to obtain the history, patient is unconscious Where patients unable to provide the history for billing purposes it is deemed a Comprehensive History. 30

31 E/M Assessment Question 4 True or False: Patient questionnaires may be used for ROS and PFSH. However, the patient questionnaire must be referenced in the note and signed by the attending physician and patient. 31

32 E/M Assessment - Answer The correct answer is true: Patient questionnaire forms may be used for ROS and PFSH, and can be obtained by ancillary personnel or provided by the patient, and signed by the attending physician. If questionnaire is separate from encounter note, the provider must reference in his/her report. 32

33 E/M Key Component - Examination Physical Examination: The extent of the examination performed is based upon clinical judgment, the patient s history, and nature of the presenting problem. A general multi-system or any single organ system exam may be performed by any provider. (See Appendix I and II) Single organ system examination involves a more extensive examination of a specific organ system. Note specific abnormal & relevant findings of the affected or symptomatic area(s) abnormal is insufficient. Include abnormal or unexpected findings of asymptomatic areas or systems. Noting negative or normal is sufficient to document normal findings in unaffected areas. 33

34 E/M Key Component Examination (continuation) Examination Documentation Guidelines: Two CMS Guidelines available (1995 or 1997) to help quantify the physical examination. Providers/Coders may use either guideline Whichever is most advantageous to the provider Must follow one guideline per patient encounter Cannot mix and match See Appendix I Elements of General Multi-System Exam See Appendix II Single Organ System Examination 34

35 E/M Key Component Examination (continuation) 1995 Guidelines Based on the number and/or extent of body areas or organ systems examined. Often used by internist and family practice Guidelines Based on the examination of specific bulleted items identified within a body area or organ system. Works well for certain specialists using the single organ system examination (dermatology, orthopedic). 35

36 Levels of Examination * Appendix I and II Examination Problem Focused Expanded Problem Focused Detailed Comprehensive Body Area or Organ System Limited Exam 2-7 Body Areas or Organ Systems Extended Exam 2-7 Body Areas or Organ Systems 8 Organ Systems or a Comprehensive Single Organ System Exam 1997 Any 1-5 Bullets Any 6+ Bullets General: 2 bullets from 6 or more organ systems/body areas or 12 bullets from 2 or more organ systems/body areas Eye/Psych: 9+ bullets All Others: 12+ bullets General: Perform all, document 2 bullets from 9 Organ Systems/body areas All Others: Perform all, document all elements in each bolded box and 1 element in each un-bolded box 36

37 E/M Assessment Question 5 A Comprehensive Multi-System Examination consists of: a. 8 systems examined utilizing the 1995 Guidelines. b. 9 systems and/or areas examined utilizing the 1997 Guidelines. c. Both a and b. 37

38 E/M Assessment - Answer The answer is (c) both a and b. Selection of Comprehensive level of examination requires documentation of: 8 systems examined under the 1995 Guidelines 9 systems/areas examined under the 1997 Guidelines 38

39 E/M Key Component Medical Decision Making (MDM) MDM refers to the complexity of establishing a diagnosis and/or selecting a management option. MDM is the function of 3 variables: 1. Number of Diagnostic and/or Management Options that must be considered 2. Amount and Complexity of Data ordered and/or reviewed 3. Risk of significant complications, morbidity and/or mortality 39

40 E/M Key Component MDM First Variable of MDM- Diagnostic and/or Management Options: Billing credit is based on a point system Self-limited, minor (1 pt.) Established problem stable, improved (1 pt.) Established problem worsening (2 pts.) New problem, without workup planned (3pts.) New problem, with workup planned (4pt.) 40

41 E/M Key Component MDM (continuation) Second Variable of MDM Amount and/or Complexity of Data: Billing credit is based on a point system Review/order of clinical lab, radiologic study, other non-invasive diagnostic study (1 pt. per category of test) Discussion of diagnostic study w/ interpreting phys. (1 pt.) Independent review of diagnostic study (2 pts.) Decision to obtain old records or get data from source other than patient (1 pt.) Review/summary old med records or gathering data from source other than patient (2 pt.) 41

42 E/M Key Component MDM (continuation) Third Variable of MDM- Risk of Complications, Morbidity and/or Mortality: Refers to patient s level of risk at the visit Determining risk is complex and not readily quantifiable Table of Risk on Slide 43 shows clinical examples Source of risk Presenting problem Diagnostic procedures ordered Management options selected 42

43 Medical Decision Making Elements Table of Risk (Billing credit is based on the highest level Level of Risk Presenting Problem(s) Diagnostic Procedures Ordered Management Options Selected Minimal One self-limited or minor problem, e.g., cold, insect bite, tinea corporis Lab tests (blood, X-rays, EKG) X-rays Urinalysis Ultrasound Rest Superficial dressings Gargles Low Two of more self-limited problems One stable chronic illness (e.g., well-controlled hypertension, non-insulin dependent diabetes, cataract, BPH) Acute uncomplicated illness or injury, e.g., cystitis, allergic rhynitis, simple sprain Non-CV imaging studies with contrast e.g., barium enema Superficial needle biopsy Lab test requiring arterial puncture Skin biopsies Physiologic tests non under stress, eg., PFTs OTC drugs Minor surgery with no identified risk factors PT/OT IV fluids without additives. Moderate 1 or more chronic illness with mild exacerbation, progression or side effects of treatment 2 or more stable chronic illness Undiagnosed new problem with uncertain prognosis, e.g., lump in breast Acute complicated injury Physiologic tests under stress Diagnostic endoscopies with no identified risk factors Deep needle or incisional biopsy Cardiovascular imaging studies with contrast and no identified risk fxs Obtain fluid from body cavity Prescription drug management Minor surgery with risk factors Decision to perform elective major surgery with no identified risk fxs Therapeutic nuclear medicine IV fluids with additives Closed treatment of fracture or dislocation without manipulation High 1 or more chronic illnesses with severe exacerbation Acute or chronic illness or injures that pose a threat to life or bodily functions e.g., multiple trauma, acute MI, pulmonary embolus, severe respiratory distress, ARF, progressive severe rheumatoid arthritis An abrupt change in neurological status Cardiovascular imaging studies with contrast with identified risk factors Cardiac electrophysiological tests Diagnostic endoscopies with identified risk factors Discography Elective major surgery with identified risks factors Decision to perform major emergency surgery Drug therapy requiring intensive monitoring for toxicity Decision not to resuscitate or to de-escalate care because of poor prognosis 43

44 E/M Helpful Guidance in MDM Documentation Diagnostic and Management Options Established diagnoses should indicate: Stable, well-controlled, worsening, failing to improve Amount and/or Complexity of Data Independent review of diagnostic test should document: visualization of image, tracing or specimen Review of old records, document findings or lack of findings. Risk of Complication Document co-morbidities, underlying diseases that increase risk of presenting illness (those that do not significantly increase complexity of MDM should not be considered) 44

45 Level of Medical Decision-Making Four levels: Straightforward Low complexity Moderate complexity High complexity Selection of MDM Level: 1. Two of the three variables or 2. Column with center circle Dx/mgt options 0-1pt 2pts 3pts 4pts Amount of data 0-1pt 2pts 3pts 4pts Overall risk Minimal Low Moderate High Level of MDM Strghtfwd Low Moderate High 45

46 Selecting Level of MDM Example: Evaluation of MDM A/P: By history, suspect possible herniated disk. Patient will be referred for MRI scan. Prescribe Motrin 800 mg. TID with food and begin Predosine dose pack to decrease inflammation. Number of dx/tx options new problem with add l workup 4 points Amt/complexity of data ordered MRI 1 point Risk prescriptions management - Moderate Level of MDM: Moderate (see next slide) 46

47 Levels of Medical Decision Making Diagnoses/ Management Options Amount and/or Complexity of Data to be Reviewed Risk of Complications, Morbidity, and/or Mortality Level of Medical Decision Making Minimal (0-1 pt) Minimal (0-1 pt) Minimal Straightforward Limited (2 pts) Limited (2 pts) Low Low Complexity Multiple (3 pts) Moderate (3 pts) Moderate Moderate Complexity Extensive (4 pts) Extensive (4 pts) High High Complexity 47

48 Selection of E/M Level Example of New Office/Outpatient Visit History section - Detailed (>4 HPI elements) Physical Examination - Detailed (2-7 extended exam) Medical Decision Making - Moderate Documentation supports a level of E & M service code. 48

49 Selection of E/M Level Example of Established Office Outpatient Visit History section - Detailed (>4 HPI elements) Physical Examination - Expanded Problem Focused (2-7 limited exam) Medical Decision Making - Moderate Documentation supports a level of E & M service code. 49

50 E/M Documentation Requirements Critical E/M Documentation Requirements: Does documentation justify the medical necessity of the service and/or procedure performed? Does the documentation support the level of service reported? 50

51 Other Significant E/M Components Counseling and Coordination of Care: An exception to the 3 key component rule exists when the visit consist predominantly of counseling or coordination of care (such as when 50% or more of visit is spent face to face with patient for counseling and coordination of care.) Time is a key or controlling factor. 51

52 Counseling and Coordination of Care Counseling as it relates to E/M coding is defined as a discussion with a patient and/or family concerning one or more of the following areas: Diagnostic results, impressions, and/or recommended diagnostic studies Prognosis Risk and benefits of management (treatment) options Instructions for management (treatment) and/or follow-up Importance of compliance with chosen management (treatment) options Risk factor reductions Patient and family education. 52

53 Documenting Time-based Coding When to Use Time: If time spent counseling and/or coordinating care face-to-face is more than 50% of encounter Face-to-face is defined: Outpatient patient must be in the same office/room with the billing provider. Time spent by the resident cannot support time based billing. Inpatient patient must be on the same unit or floor with the billing provider. 53

54 Documenting Time-based Coding Documentation Requirements: (All 3 Necessary) Amount of time counseling Total time spent on encounter/visit What was discussed or coordination activities 54

55 E/M Assessment Question 6 Time is considered the key or controlling factor in determining a level of service if counseling and/or coordination of care dominates the total face-to-face encounter with the patient. The physician must document: a) Total encounter time with the patient and the time spent counseling. b) What was discussed. c) The time spent counseling only. d) A & B e) B & C 55

56 E/M Assessment - Answer The answer is (d) A & B. The total length of time for the visit and total length of time counseling and coordinating care as well as the nature of the counseling and coordination of care must be documented in the medical record. 56

57 Critical Care Services (CCS) Critical Care Services Time Based Direct delivery by a physician of medical care for a critically ill/injured patient. Critical Illness/Injury Impairs one or more vital organ system High probability of imminent or life threatening deterioration of condition 57

58 Critical Care Services (CCS) (continuation) Duration of CCS to be reported: Time physician spend evaluating, providing care and managing patient Time must be immediately at bedside or on floor/unit so long as physician immediately available Must be medically necessary and reasonable Usually provided in critical care units or emergency departments Example: Time spent reviewing lab results or discussing ill patient s care with other physicians may be reported as CCS even if not at bedside if physician s full attention to management of the critical patient. 58

59 Critical Care Services (CCS) (continuation) For CCS Physician Must Document: Total time spend providing CCS CCS provided For each date and encounter entry Time spent performing procedures not bundled into CCS may not be counted toward CC time Non-continuous time for CCS may be aggregated More than one physician can provide CCS but physicians of same specialty in same group practice are paid though a single physician. 59

60 Critical Care Services (CCS) (continuation) Coding CCS: CPT Codes to report total duration of time CPT Code for first minutes of CCS on a given calendar date may use only once per calendar day. CPT Code additional blocks of time - up to 30 minutes each beyond the first 74 minutes of CCS. Reporting CPT Code prerequisite to CPT Code If less than 30 minutes do not report separately using CCS Codes report as appropriate E/M code. Only one physician can bill for a particular period of time. 60

61 E/M Code Assignment Considerations Code assignment in the CPT E/M Section vary according to three factors: Place of Service (e.g., office, hospital, ER, nursing home) Type of Service (e.g., consultation, admission, office visit) Patient status (e.g., new patient, established patient, inpatient, outpatient)* * See Slide 65 for new ad established patient. 61

62 E/M Code Assignment Considerations (continuation) Each E/M category codes includes three to five levels of service.* The levels indicate the wide variations in skill, time, effort, responsibility and knowledge required to diagnose, treat or prevent an illness or injury. * See Appendix III for codes. 62

63 General Coding Considerations Not medically necessary or appropriate to bill a higher level of E/M service when a lower level of service is warranted. The volume of documentation should not be the primary influence upon which a specific level of service is billed. Selection of code for the service should be based upon the content of the service. CMS states: Medical necessity is the overarching criterion for payment in addition to the individual requirements of a CPT code. 63

64 Coding Considerations The CPT code or service is the driving force behind reimbursement. The ultimate responsibility for correct coding lies with the provider of services. 64

65 Code Assignment Considerations New patient Has not received any professional E/M services from the physician or another physician of the same specialty who belongs to the same group practice within three years. Established patient - Has received E/M services from the group within three years. 65

66 Key Components of E/M The First Time Encounter For New Patients, Hospital Admits, & Consultations All three components required History Exam Medical Decision-Making Follow-up Encounter Established Visit and Subsequent Hospital Visit Two out of three components required History and/or Exam and/or Medical Decision-Making 66

67 Code Assignment Assessment- Question 7 True or False: A patient was seen by Dr. Smith of UCLA Rheumatology two years ago and returns to see a different UCLA Rheumatologist (same practice group), the patient is considered new. 67

68 Code Assignment Assessment-Answer The answer is false. The patient was seen two year ago and now a follow-up visit with a new physician from the same group practice is considered an established patient. Follow-up encounter codes should be used. 68

69 ICD-9CM Coding Diagnosis The system of diagnosis codes used is the International Classification of Diseases, 9 th revision, Clinical Modification (ICD-9CM) and composed of codes with three, four or five digits. The primary diagnosis must support or justify the physician s services. The ICD-9 diagnosis code must support the CPT code in order to be reimbursed. Inpatient-consultant s primary diagnosis would be the reason for the consult and not necessary the admitting diagnosis. 69

70 ICD-9CM Coding Diagnosis (continuation) The highest level of specificity should be given when establishing a diagnosis. Hypertension has sub-classifications, malignant and benign. Sites of injuries, infections, and burns should also be provided. Therefore, try to avoid unspecified diagnoses and codes. Example: malignant hypertension ICD-9 diagnosis code benign hypertension ICD-9 diagnosis code hypertension, unspecified ICD-9 diagnosis code

71 ICD-9CM Coding Diagnosis (continuation) The highest level of certainty should be given when establishing a diagnosis. Suspected or Rule Out diagnoses cannot be coded. If the physician is working only with phenomena and has not yet formed a diagnosis, then the sign, symptom, or laboratory abnormality should be selected. Document all conditions that co-exist at the time of the visit that require or affect patient care, treatment or management. Conditions that were previously treated and no longer exist should not be coded. 71

72 Coding Assessment Question 8 True or False: The CPT and ICD-9CM codes reported on the health insurance claim form or billing statement should be supported by the documentation in the medical record. 72

73 Coding Assessment - Answer The answer is false. The ultimate responsibility for correct coding lies with the provider of services. All diagnosis and procedure codes MUST be supported by clear documentation report and/or note. 73

74 Modifier 25 Append a Modifier 25 to an E/M code if a significant, separately identifiable E/M service is performed by the same physician on the same day of a procedure or other service. The patient s condition must require E/M services above and beyond what would normally be performed in the provision of the procedure. The necessity for the E/M service may be prompted by the same diagnosis as the procedure. Example: A preventative service (routine annual exam) with an E/M code (treatment for hypertension) Example: Patient visit for follow-up hypertension where provider also performs abscess drainage. 74

75 Modifier 25 A new patient E/M service is considered separate from the same day surgery or procedure no Modifier 25 needed. For an established patient, if the E/M service resulted in the initial decision to perform a minor procedure (0-10 days global period) on the same day and medical necessity indicates an E/M service beyond what is considered normal protocol for the procedure, Modifier 25 is appropriate. To determine the correct level of E/M service to submit, identify services unrelated to the procedure and use as E/M elements. Clearly mark the encounter form to indicate that a Modifier 25 should be attached to the E/M. 75

76 Modifier 25 (continuation) Example of a valid submission of Modifier 25 The patient came in to the office for her scheduled 2 nd therapeutic knee injection. On the same day, she presented with neck pain that has been bothering her sleep for the past 3 days. The physician then added a separate E/M service. Codes: (established patient office visit) (therapeutic knee injection) In this example, Modifier 25 should be billed with the E/M service. 76

77 Coding Assessment Question 9 Which of the following correctly classifies a case in which a patient has both a level 2 E/M service (99212) and an indirect laryngoscopy (31505) performed in an outpatient clinic? a and b and c and

78 Coding Assessment - Answer The answer is b (31505 and ). Modifier 25 is appended to an E/M code (99212) if a significant separately identifiable E/M service is performed by the same physician on the same day of a procedure or other service (31505). 78

79 References Centers for Medicare & Medicaid Services (CMS) Documentation Guidelines for E & M Services Centers for Medicare & Medicaid Services - Medicare Claims Processing Manual, Publication 100-4, Chapter 12, Sections Selection of Level of Evaluation and Management Service and Critical Care Services Current Procedural Terminology (CPT) 2009 Professional Edition. 79

80 Appendixes Appendix I Elements of General Multi-System Exam Appendix II Single Organ System Examination Appendix III - Codes 80