This page is expanded from a column by David Stern, MD, CPC in the Journal of Urgent Care Medicine, January 2007

Denials for an E/M Code Plus a Procedure

There are a few reasons that payors deny payment for an E/M in addition to a procedure:

Missing modifier
If you perform both a procedure with a 0- or 10-day global period and a separate documented E/M on the same day, always use modifier -25 for the E/M. Adding the modifier should reduce denials and costs of rebilling. Note: If the procedure has a 90-day global period, attach modifier-57 to the E/M instead of modifier-25.

Bundling issues
Procedure codes generally include a basic level of evaluation of management. The payor may assume that an additional E/M code is unnecessary; in the urgent care setting, however, bundling the E/M into the procedure code is often not appropriate.

Payor policy
Some payors consistently deny payment for an E/M in addition to certain, sometimes even all, procedures.

Lack of supporting documentation
Some payors who automatically deny an E/M in addition to a procedure may pay if you provide supporting documentation. For example, some payors deny payment for an E/M when billed in a claim along with a code for ear wax removal. Even in these cases, however, payment might be obtained by submitting proper documentation, especially if that documentation demonstrates a problem that is separate and additional to the ear wax impaction.

Using Modifier -25

Generally, all urgent care procedures with a 10-day global period (and many others with a 0-day global period) should have modifier -25 attached to the E/M code. Per the AMA definition, modifier -25 should be used when a “significant, separately identifiable E/M service above and beyond the other service provided or beyond the usual preoperative and postoperative care associated with the procedure that was performed” is provided. This rule is sometimes difficult to interpret, and gray areas exist where not all coders or payors agree. Here are some scenarios and guidance on whether or not to use the modifier:

Patients who are new to a practice: The initial E/M (99201- 99205) for a new patient who also has a minor procedure (0- to 10-day global period) performed on the same day should not require the -25 modifier on the E/M code. Since the patient is unknown to the provider, his baseline history, medications and basic health status must be determined prior to doing the “usual preoperative care.”

Problems that require significant evaluation beyond the procedure: For example, a patient presents with knee pain. After the physician evaluates the knee, he determines that the problem may be gout or infectious arthritis. The joint needs to be aspirated and the fluid sent to the lab for analysis in order to confirm the diagnosis. Use the E/M code with a modifier (for example, 99213-25), as well as the knee joint aspiration procedure code 20610. Thus, when a new problem requires more than a cursory review, the visit generally qualifies for an E/M with modifier -25.

“Established patients” with additional medical problems: Sometimes an established patient in need of a procedure has an underlying medical problem that will complicate the given procedure. Your clinic, knowing about the underlying condition, should evaluate and manage the problem appropriately. Take, for example, a patient who presents with an abscess and who also suffers from AIDS, valvular heart disease, diabetes, or elevated blood pressure. The physician should document evaluation and management twice: for the problem that is addressed by the procedure and for the complicating problem. An E/M with modifier -25 is always appropriate in addition to the code for the procedure.

“Established patients” with a second medical problem requiring attention: An E/M is always appropriate when a patient receives evaluation and management services for any problem other than the problem requiring the procedure. For example, a patient may present with a laceration. In the course of evaluation and management, the physician discovers that the patient has been suffering from chronic diarrhea. The physician begins the work-up by ordering collection of a stool specimen for culture and microscopic examination for ova and parasites. The clinic should use the laceration code and the E/M code with modifier -25.

“Established patients” seen in the urgent care setting: Sometimes not enough information is known about an “established patient” to go through with a procedure without finding out that information. A typical urgent care center is quite different from a typical primary care clinic. In the urgent care center, few patients are truly established with the provider. Most established patients are, in effect, new patients. Before preoperative care can begin, they will need a full history and physical. Thus, before a procedure can take place in the urgent care center, a thorough history and physical are almost always required to evaluate the past medical history, medications, and current symptoms. This is why an E/M code with modifier -25 can be appropriate even when there is no additional or underlying problem.

It is one thing for Dr. Welby at a primary care office to say, “Oh, Johnny, so you cut your finger again. You need to be more careful with your whittling knife. Don’t worry, we’ll sew that up in a jiffy. Since you don’t have any other problems except for that heart murmur, you should do great.”

It is another matter entirely for urgent care physician Dr. Urgentowitz to see the same patient and inquire about diabetes, history of infections, the relevance of the heart murmur, and the patient’s experience with previous injuries. Then Dr. Urgentowitz must examine the patient’s skin, eyes, heart, lungs, and peripheral vasculature to evaluate the status of known conditions and to see if there is an additional underlying or complicating medical condition.

Generally, a separate E/M is appropriate for patients seen in an urgent care center. Of course, if the urgent care physician also functions as the primary care provider for the patient, the patient is truly established with the practice and an additional E/M is often not appropriate.

YOU DO NOT NEED A SEPARATE DIAGNOSIS FOR MODIFIER -25, Although Some Payors Seem to Think That You Do

It is a commonly-believed myth that, to use this modifier, the patient must have a “significant separately identifiable” problem that is managed on this visit. But the AMA definition of modifier -25 clearly denotes that this is not true:

“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.”

A problem arises when overzealous payors (in direct contradiction of AMA guidelines) require physicians to treat a second condition before they will give payment for an E/M with modifier -25. It is the E/M note, not a second presenting problem, which must be “significant and separately identifiable.” Nonetheless, quite a few large payors will not reimburse for E/M codes with this modifier unless documentation of a second diagnosis and medical records supporting separate E/M services for that second diagnosis are provided.

Attaching Modifier -25 to an E/M Where the Modifier Was Not Required
Payors almost never deny payment for attaching modifier -25 to an E/M code where the modifier was not required. You should, however, be careful not to use modifier -25 unless a procedure is performed because overuse of the modifier may trigger a payor audit.

Make Sure to Separate the E/M Note and the Procedure Note

If your clinic is audited and the carrier denies payment because of inadequate documentation, you cannot simply make your patient records longer. The content of the patient record is what is important, not its length. In order to support both an E/M code and a procedure code, the visit record must contain documentation of the level of evaluation and management AND a significant, separately identifiable procedure note. Try not to include the procedure note within the evaluation and management note, as some auditors will deny the code because the procedure note was not “separately identifiable” from the evaluation and management. Some coders even recommend a separate page, template, or dictation for each E/M and each procedure note.