The integrity of the American Medical Association Current Procedural Terminology (CPT™) codes requires that each service provided be accurately defined and reported. Moreover, proper application of the Resource-Based Relative Value Scale (RBRVS) requires that these codes and associated modifiers be used by both physicians and payors in a similar manner that accurately reflects the associated physician work.
Such physician work involved in any physician service is further defined in its pre-service, intra-service and post-service work, the value of which is included in the RBRVS. If two services provided on the same date have no overlap in the components of their physician work, there can be no justification for bundling such services together as if only one service were provided.
To allow clear communication between provider and carrier, the AMA instituted the CPT -25 modifier to designate a separately identifiable Evaluation and Management (E/M) service performed on the same date as another procedure. Modifier -25 indicates that this separate E/M service is above and beyond another service provided, or beyond the usual preoperative and postoperative care associated with another procedure that was performed.
CPT more recently introduced modifier -59 to indicate a "separate procedure" unrelated or distinct from other procedures or services provided on the same date. This clarifies that this procedure is not one that can be considered to be a component of another procedure, but is distinct and independent, and therefore should be considered for separate payment.
The American Academy of Dermatology has received numerous complaints from dermatologists about the bundling by insurance carriers when a separate documented E/M service was provided on the same date as another procedure, such as a skin biopsy or other surgical procedure. Carriers must recognize that in the course of skin examinations for unrelated problems, dermatologists often discover suspicious lesions that warrant a skin biopsy. The following illustrates why such bundling is completely inappropriate.
An initial office visit for the evaluation and management of a new patient, e.g. CPT code 99202, requires an expanded problem-focused history, an expanded problem-focused examination, and straightforward medical decision-making. This service has a transitional RVU of 1.74 for 2008. There is no part of any of the three components of this E/M service that involves a separate surgical procedure, such as a skin biopsy. The skin biopsy procedure, CPT code 11100, includes the pre-service, intra-service and post-service work related only to the performance of this procedure, and it does not include any of the three components of the E/M service. The skin biopsy procedure has a transitional RVU of 2.4 for 2008.
Both of these services have completely different pre-, intra- and post-service work upon which their individual values have been established. The physician work in the provision of these two procedures does not change, whether the services are provided on the same date or on a different date of service. It is well accepted that when these services are performed on different dates, all carriers routinely allow payment for each of these separate services. Unfortunately, some insurance carrier claims-processing practices have failed to recognize that it is just as appropriate to pay for both services when they are performed on the same date.