By Dirk Elston, MD, December 01, 2011
I saw a patient in the morning and started treatment for a pruritic rash. The patient returned that afternoon with marked worsening of the rash. I saw the patient again and a different treatment was prescribed. Do I report a second E/M code with a 25 modifier for the second visit?
No. Modifier 25 is used to identify significant, separately identifiable evaluation and management (E/M) services performed by a physician on the same date as a procedure. The modifier prevents inappropriate bundling of the E/M with the procedure by a CCI edit (see May’s column on CCI edits). It should not be appended to a second E/M code on the same date of service. It would be best to add an addendum to the original note in the medical record, recalculate the level of service, and submit a single claim for the service. In exceptional circumstances, if the physician truly has to spend significant time reevaluating the same problem again with new questions and exam, a separate E/M code may be justifiable. Documentation must be complete and clearly justify the medical necessity of the second visit. Note that HPI and other history elements counted in the morning cannot be counted again in the afternoon for the same visit. If significant physician time is spent gathering history and performing the physical exam, and more than half the time is spent in face-to-face counseling, the visit can be coded by time.
Highmark Federal Services has noted that there may be rare instances when two visits with the same provider on the same day must stand alone. In these rare circumstances, the documentation should clearly provide evidence that the second visit indeed occurred, the reason for the additional services, and clear documentation of medical necessity. Expect that the claim for the second E/M service will be denied and that you will have to appeal the claim, providing full documentation of the services provided and medical necessity, as well as why the second visit had to be reported separately, rather than simply adding an addendum and recalculating the correct code for a single claim.[pagebreak]
When auditors review claims with modifier 25, they first identify all documentation specific to the procedure or service performed on that date of service. All customary pre- and post-operative counseling related to the procedure is bundled with the procedure. In order to justify a separate E/M code, the note must clearly document cognitive services that are separate and distinct from the pre- and post-operative counseling. Note that some Medicare carriers have stated that the decision to perform a procedure with a 10-day global period is not adequate justification for a separate E/M code. My advice is to be sure that the separate and distinct cognitive services are clearly documented.
After identifying documentation that relates specifically to the procedure, the auditor should consider all of the remaining documentation to determine if there is a significant, separately identifiable E/M service that was rendered and documented, and if the required components of the E/M service were “reasonable and necessary” as defined in the Social Security Act, Section 1862(a)(1)(A). If the prior two conditions are met, they will determine the level of care supported by the documentation. This remains a difficult and controversial area that has become a focus of audits. My advice is to template your notes so that the documentation related to the procedure is clearly identifiable and readily distinguishable from the documentation that supports the separate E/M service.
Example: You prescribe a topical medication in the morning and the patient stops by in the afternoon asking for a less expensive generic substitute.
In most cases, the substitution would not require an extensive cognitive evaluation, so it is unlikely that a second visit charge would be justifiable. If some extra cognitive work is necessary, it may be simplest to add an addendum, recalculate the correct level of service, and submit a single claim.