Health Information Management

Q&A: Reporting modifier -25 to indicate a separate E/M service

JustCoding News: Outpatient, February 10, 2010

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QUESTION: A patient came to the HIV clinic for a check-up, and received a physical examination. The patient also received Buprenorphine p.o. (i.e., by mouth) treatment for drug dependence. Typically, we observe the patient for one to two hours after he or she has received the drug. Can we append modifier -25 (Significant, separately identifiable evaluation and management [E/M] service by the same physician on the same day of the procedure or other service) to the E/M code?

ANSWER: This depends on the documentation in the medical record. Why did the patient come to the clinic? Was it for the drug treatment or the physical exam?

If the purpose of the visit was the drug treatment, the code reporting the drug treatment includes the observation time, so the observation does not support a separate E/M code at all. The standard of care for the provision of this drug includes the observation of the patient for a time after receipt of the drug to monitor for any adverse effect. Because this is standard protocol, reimbursement for the observation is included in that procedure code and not separately reportable.

This is why we need a clear understanding of the term “check-up.” To report the E/M code, you need notes documenting an equal or greater level of patient history and/or medical decision-making (depending upon whether the patient is new). You need to have documentation supporting a completely separate E/M service, outside of the drug provision protocol.

If the physician recommended and administered the drug treatment as a result of the examination, then you could report this treatment in addition to the E/M code, but you would not append modifier -25.

Editor’s note: Shelley C. Safian, MAOM/HSM, CCS-P, CPC-H, CHA, of Safian Communications Services in Orlando, FL, answered this question. She is a senior assistant professor who teaches medical billing and insurance coding at Herzing University Online in Milwaukee, WI. E-mail her at ssafian@embarqmail.com.

This answer was provided based on limited information submitted to JustCoding.com. Be sure to review all documentation specific to your own individual scenario before determining appropriate code assignment.



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