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Benchmarking Resources; 92225 vs. 92226


Answers from our coding expert on questions regarding benchmarking resources; 92225 vs. 92226; procedures in visit notes; and chronic care management.


Q: I am looking for a resource to incorporate into an E&M coding distribution graph that we will be providing to each of our providers monthly. Do you have any resources or suggestions for where I can find E&M coding distribution percentage benchmarks by specialty?

A: Most people use the Medicare annual utilization data by specialty, available at (At time of publication, only 2012 data was available, however, 2013 will be available soon.)

It has become increasingly hard to get Medicaid or commercial profile data.

If anyone in your group belongs to the Medical Group Management Association (MGMA), they may be able to obtain productivity or profile data that the association gathers from its constituency.

When creating a comparison for your physicians, I would suggest using both resources (Medicare data and MGMA data) if possible. Ideally you would have Medicare information at the top of a page, MGMA information below that, the practice or specialty summary below that, and the data on your individual physicians below that. This would make for a useful comparison.

92225 VS. 92226

Q: I have been under the impression that the use of codes 92225 and 92226 - ophthalmoscopy, extended with retinal drawings, etc. - initial or subsequent, is dependent on whether I have seen that patient before, the same way that I would pick a new or established patient code. Now my office manager says that is incorrect. What is the proper use of these codes?

A: These codes are not identified by new patient or established patient, but by whether you are billing for the initial or subsequent performance of the test. These codes are also frequently monitored or audited for this very reason. In fact, the Office of Inspector General's Work Plan for 2015 states, "We will review Medicare claims data to identify potentially inappropriate and questionable billing for ophthalmology services ..."

Make sure you are using these codes correctly.


Q: I usually include my procedures in my visit note. Is this allowed? Can I include imaging results in my note as well?

A: For procedures and E&M, you need to create some separation. Most state Medicare contractors and commercial payers have some very specific guidelines for billing a procedure with an additional E&M.

The concern I have is just how distinct the E&M is from the procedure, and whether you are documenting it distinctly. Remember that the modifier 25 you put on the visit code means "separate, significant, and identifiable" from the procedure, so be sure to separate them. The best advice is to label it as a "Procedure Note."

Imaging services have some similarities and some differences. If you are just referencing a finding by another provider that interpreted the film or image, in the body of your note you can write, "CXR neg." But, if you are billing for the imaging interpretation, you need to have a formal note describing your finding.


Q: If our physician sees a patient and performs an office visit, an EMG, and a small nerve biopsy during the same date of service, will his reimbursement or RVUs be lower than if he performs these procedures on separate days?

A: No, as long as the physician clearly labels the procedures as procedures, puts the modifier 25 on the E&M code, and writes a good note.

The only danger is if he lumps it all together and the payer "bundles" the visit into the procedure. If the physician spells out all of his diagnosis codes and assigns signs and symptom codes to the procedures, it should be fine.


Q: I want to check with you on EEG coding. My provider does the interpretation only. She thinks she should be using a 95816 or a 95819, both with a 26 modifier. Is this correct? Also, can she use 99490 - chronic care management services - for her chronic Parkinson's patients?

A: From your question it sounds like the EEG equipment is either not in your office or the EEG is not being performed by your physician. If the physician only does the interpretive components of those two tests, then she is correct in billing them with modifier 26.

The new 99490 code for chronic care management services might well be applied to a Parkinson's type patient. This is a new code, its earliest date of service was Feb. 1, 2015, so we still don't have much of a track record on this.

Review the guidance in the CPT manual and the Medicare guidance to be certain that you meet all the requirements. Sometimes, although the codes and the services seem to match, you may have issues meeting the requirements. For instance, you need to have the patient's consent, provide 20 minutes worth of non-face-to-face care management services per calendar month, use a certified EHR for specified purposes, maintain an electronic care plan, ensure beneficiary access to care, facilitate transitions of care, and coordinate care.

You cannot bill for these services unless you have each of these capabilities for providing chronic care management.

Bill Dacey, CPC, MBA, MHA, is principal in the Dacey Group, a consulting firm dedicated to coding, billing, documentation, and compliance concerns. Dacey is a PMCC-certified instructor and has been active in physician training for more than 20 years.

This article originally appeared in the May 2015 issue of Physicians Practice.

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