Health Information Management

Coding an E/M with other services

APCs Insider, June 4, 2004

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QUESTION: Is it appropriate to bill a room charge with a low-level E/M code (such as 99201 or 99202) on the same day a patient has a surgical procedure or receives preoperative services?

ANSWER: There are several scenarios in which this question could apply. Here are some examples of how to code in various circumstances:

  • A patient receives a surgical procedure in your facility. It is inappropriate to bill separately for an E/M visit for the same encounter. The E/M of this patient during his or her encounter is considered part of the surgical procedure reimbursement.
  • A patient visits your facility on the same day as he or she receives the surgical procedure, e.g., laboratory tests. It is inappropriate to bill a separate E/M visit charge for the preoperative visit.

There are rare instances where billing both may be permissible.

  • A patient receives a surgical procedure on an outpatient basis, is discharged to home, and returns to the facility for a separate and distinct complaint. If the two encounters were for separate complaints, you could add modifier -25 to indicate a separate and distinct service. Although this situation is possible, it not common. Remember, the Office of Inspector General is looking closely at use of modifier -25 and care should be taken to ensure it is used appropriately.
  • A patient visits the facility for preoperative services and returns for an unrelated service. For example, if the patient was involved in motor vehicle accident later during the same day, you could bill the E/M visit code for the motor vehicle accident and the preoperative services that may or may not include an E/M on the same claim.

    Additional information regarding modifier -25
    The Current Procedural Terminology (CPT-4) manual gives the definition of modifier -25 as, "Significant, Separately Identifiable Evaluation and Management Service by the Same Physician on the Same Day of the Procedure or Other Service."

    CPT also offers the following explanation: "The physician may need to indicate that on the day of a procedure or service identified by a CPT code was performed, the patient's condition required 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. 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. This circumstance may be reported by adding the modifier -25 to the appropriate level of E/M service..."

    Billing requirements

    1. Should a separately identifiable E/M service be provided on the same date that a diagnostic and/or therapeutic procedure(s) is performed, information substantiating the E/M service must be clearly documented in the patient's medical record to justify use of the modifier -25.
    2. Modifier -25 may be appended only to E/M service codes and then only for those within the range of 99201-99499.

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