Same-Day Patient Visit and Procedure Can Be Reimbursed

August 5, 2015
G. John Verhovshek, MA, CPC

Insurers typically do not reimburse an E&M service and procedure performed on the same date of service. But, careful documentation can change that.

All billable medical procedures include an "inherent" evaluation and management (E&M) component. As such, insurers typically do not reimburse an E&M service if the provider also performs a minor procedure for the same patient on the same date of service. Payment will be made, however, if you meet all of the following requirements:

1. The E&M service is medically necessary, as supported by provider documentation. For a claim to stand up in an audit, a medical reviewer must be able to see the work involved. This might be evident through possible new or more severe symptoms in the patient's history, or possibly a change in a patient's treatment plan.

When an E&M service leads to an unplanned, same-day procedure, be sure that documentation clearly shows that the decision to perform the procedure was made during the encounter.

2. The E&M service must "go beyond" the usual E&M component, included as part of the minor procedure. Generally speaking, if the E&M service is unrelated to the minor procedure (i.e., the E&M takes place for a different concern/complaint), the E&M service may be reported separately. Additionally, if the E&M service occurs due to exacerbation of an existing condition, or other change in patient status, that service may be reported separately as long as it is independently supported by documentation.

Note: A minor procedureis any procedure/CPT® code with a zero-day or 10-day global period, as defined by Medicare's Physician Fee Schedule Relative Value File. Examples include many injections, minor integumentary repairs, and endoscopic procedures (e.g., diagnostic colonoscopy). You can find a global period look-up tool on the CMS website.

3. Documentation must support both the minor procedure and a separate, independent E&M service (e.g., the E&M documentation must "stand alone"). Ask yourself, "Can I pick out from the documentation a clear history, exam, and medical decision-making apart from any other procedures performed on the same day?"

Although not required, best practice is to separate the E&M note from the procedure note.

4. The appropriate E&M service code must be reported with 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) appended. The American Academy of Family Physicians (AAFP) recommends that physicians ask themselves the following questions to help determining if modifier 25 is appropriate:

* Did you perform and document the key components of a problem-oriented E&M service for the complaint or problem?

* Could the complaint or problem stand alone as a billable service?

* Is there a different diagnosis for this portion of the visit?

* If the diagnosis is the same, did you perform extra physician work that went above and beyond the typical pre- or postoperative work associated with the procedure code?

American Medical Association (AMA) guidelines support coding for a minor procedure and a separate, significant same-day E&M with modifier 25. CPT Assistant (May 2011) shows an example:

"A 4-year-old slips on the edge of a pool, strikes the mandible and experienced a 3.5-cm serrated and curvilinear, full-thickness laceration of the chin. The child's pediatrician elects to widely excise the serrated skin margins and undermine the dermis from the subcutaneous tissue to reduce the tension on the suture line. The wound is then approximated in layers with absorbable, interrupted sutures and a running subcuticular closure.

"This procedure would be reported 13132 Repair complex, forehead, cheeks, chin, mouth neck, axillae, genitalia, hands and/or feet; 2.6 to 7.5 cm. Any significant, separately identifiable evaluation and management (E&M) service performed in addition to the wound repair would be reported separately using modifier 25."

Centers for Medicare & Medicaid Services (CMS) Transmittal R954CP (Medlearn Matters Number: MM5025, Change Request 5025) likewise instructs us to apply modifier 25 for "a significant, separately identifiable E&M service that is above and beyond the usual pre- and post-operative work for the service," and to "appropriately and sufficiently" document medical necessity for both the E&M service and the other service or procedure.

Both the procedure and the separate, same-day E&M service must be linked to a diagnosis substantiated in the medical record. The diagnoses supporting each service may be the same or different. Per Transmittal R954CP, "The E&M service may be prompted by the symptom or condition for which the procedure and/or service was provided. As such, different diagnoses are not required for reporting of the E&M services on the same date" [emphasis added].

Finally, turn to modifier 57 Decision for surgery - rather than modifier 25 - to report a separately identifiable E&M service that occurs on the same day as, or on the day before, a major surgical procedure (a procedure or service with a 90-day global period), and that results in the physician's decision to perform the surgery, according to the Medicare Claims Processing Manual, section 40.2.