Are you billing an E/M when you shouldn’t? Part I

Monday, April 17, 2023

Each time you submit an E/M (evaluation and management) code with another service, are you following the CPT and NCCI Modifier 25 guidelines? If not, you have a compliance issue that needs to be addressed.
The misuse of Modifier 25 occurs when an E/M is billed with one of the services below:

  • Injection
  • Procedure
  • Yearly physical
  • Medicare Annual Wellness visit

It is important to understand Modifier 25 CPT guidelines are followed. The crucial part of the guidance is the E/M must be significant, separate, and above and beyond the other service/procedure provided. The same applies to procedures that have a global surgical package. This puts a target on scheduled services such as injections, planned procedures, and physicals.

Novitas published a document Modifier 25 tips that include questions that should be asked before an E/M is reported with another service/procedure. Two (2) examples are provided below, and the link above provides three (3) more scenarios.

Was the procedure or service scheduled before the patient encounter?
If Yes, it is not medically necessary to bill for an E/M with Modifier 25

Example:

  • A patient was scheduled to have a lesion removed from her right leg.
  • The physician examined the lesion, infiltrated the lesion with 1% lidocaine. The lesion was removed, and a simple closure (11401) was performed.
  • The sole purpose for the visit was for the lesion removal; therefore, billing an E/M with Modifier 25 would not be appropriate.

Is payment allowed for an annual wellness visit (AWV) or an initial preventive physical exam (IPPE) on the same day as an E/M?

  • Yes, payment is allowed for medically necessary E/M services at the same visit as the AWV or the IPPE when the E/M service is clinically appropriate and medically necessary to treat the patient’s illness or injury or to improve the function of a malformed body member.
  • Some of the components of a medically necessary E/M service, for example, a portion of the history or physical exam, may have been part of the AWV or the IPPE and should not be included when determining the most appropriate level of E/M service.

If all the requirements are met, Modifier 25 can be appended to the E/M code.

Example:

  • An established patient was scheduled for their AWV today. Yesterday they fell and hurt their knee.
  • The physician performed and documented a medically necessary E/M service at the same visit as the AWV. All duplicative elements were backed out of the E/M and the physician billed a 99212 with Modifier 25 in addition to the AWV.

Look for Part II of our article coming soon!

 

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