Health Information Management

Q/A: Billing ED visit and OR procedure

APCs Insider, April 30, 2010

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Q: A patient is seen in the ED and based on the findings is sent to the OR for a procedure. May a hospital bill for both the ED visit and the OR procedure?

A: The hospital may bill the ED E/M code separately, with modifier -25 (significant, separately identifiable evaluation and management service by the same physician on the same day of a procedure or other service), if it is significant and separately identifiable from the surgical service as defined by modifier -25. If the visit doesn’t meet the requirements for modifier -25, don’t bill it separately.

A visit billed without modifier -25 is subject to a return-to-provider edit in the OCE (refer to edit 21). Confusion surrounds this issue because of Program Memorandum A-00-40 that instructs providers to always append modifier -25 to ED E/M codes when provided on the same day as a surgical procedure. However, CMS subsequently clarified in FAQ 2389 (published 10/14/2003, updated 3/04/10)  that use of modifier -25 must be consistent with its definition, even in the ED. CMS further states in the same memorandum that modifier -25 may be used when ED visit services result in a decision for surgery, presumably because modifier -57 (decision for surgery) is not an allowed modifier for hospital providers.

When ED services result in a patient being taken to the OR for a procedure, the likelihood of significant and separately identifiable work in the form of triage, nursing assessment, and other minor packaged services is great. In most cases, the expectation is that the visit is be eligible for separate billing with modifier -25. Your question also seems to indicate that the visit services resulted in the decision for surgery in which case CMS has instructed that appending modifier -25 is appropriate. In either case, documentation must support that the service was either significant and separately identifiable or resulted in a decision for surgery to support use of modifier -25.

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