What is the appropriate use of E/M modifiers during the same encounter as a procedure?


By Faith McNicholas

Q: A patient presents for follow-up of a clinically pre-malignant lesion of the face previously treated with topical 5-fluorouracil with lesion persistence. The decision is made to treat the lesion with LN2. The patient also requires a refill of a topical steroid to treat lichen planus. How do you report this encounter?

A: Because the pre-malignant lesion was previously addressed with no improvement, the provider obtains a problem-focused history from the patient regarding prior treatment and a problem-focused exam of the lesion site(s), and then decides to treat the lesion with LN2.

The provider then reviews the patient-completed medical history form and the clinical staff obtains vital signs from the patient, paying particular attention to issues relating to the lichen planus. 

An expanded, problem-focused history and examination is performed. A treatment plan is formulated and developed.

Discussion of the diagnosis and treatment options with the patient is performed, the medication list is reconciled, and prescription(s) are written. Medical record documentation is completed.

The patient is advised about how to handle (with the help of clinical staff) any treatment failures or adverse reactions to medications that may occur after the visit. 

All necessary care coordination, telephonic or electronic communication assistance, and other necessary management related to the office visit are addressed.

The safest, practical thing dermatologists should remember: Documentation must indicate that the E/M service was above and beyond the procedure and, upon review, must stand on its own merit to support the level of service reported.

What to report

In this circumstance, it is appropriate to report an evaluation and management (E/M) service at the same time as the procedure.

Most dermatology practices have had a claim denied or received a request for medical records after submitting a claim with an E/M service performed on the same date of service (DOS) as a procedure. In the past few years, payers have increased their scrutiny of medical record documentation to ensure that reimbursement for services rendered matches documentation in the patient record.

To rub salt in the wound, the National Correct Coding Policy Manual (NCC) for Part B Medicare Carriers, which is revised quarterly, recently released Version 19.2. It took effect July 1, 2013, and in this version, The Centers for Medicare and Medicaid Services (CMS) added enhanced narrative under the Integumentary section code edits that re-emphasizes the reporting of an E/M service on the same DOS as a procedure.

Because NCCI edits are applied to same-day services performed by the same provider to the same patient, certain global rules apply. An E/M service performed on the same DOS as a procedure with a global period of either ‘0,’ ‘10,’ or ‘90’ days can be separately reported under limited circumstances.

The NCCI narrative states, “If a procedure has a global period of 000 or 010 days, it is defined as a minor surgical procedure. E/M services on the same date of service as the minor surgical procedure are included in the payment for the procedure. The decision to perform a minor surgical procedure is included in the payment for the minor surgical procedure and should not be reported separately as an E/M service.

However, a significant and separately identifiable E/M service unrelated to the decision to perform the minor surgical procedure is separately reportable with modifier 25. The E/M service and minor surgical procedure do not require different diagnoses. If a minor surgical procedure is performed on a new patient, the same rules for reporting E/M services apply.”

Regional preferences

Although the NCCI edits are considered to be exhaustive, they still do not contain all carrier or payer edits, because some Medicare and commercial carriers may have separate edits not included in the NCCI. For example, the use of modifier 25 varies among CMS carriers; some prefer providers to include modifier 25 when reporting a new patient E/M service with a procedure, whereas others don't. 

Therefore, dermatologists should clarify with their regional Medicare carriers to establish the regional preference about whether to report modifier 25 on a new patient code. Use of a modifier when it is not appropriate or needed can result in claim denial with remark code "inappropriate use of modifier." Check with your commercial carriers for specific implementation rules to avoid claim denials and subsequent claim appeals.

The new NCCI narrative further states that, "For major and minor surgical procedures, post-operative E/M services related to recovery from the surgical procedure during the postoperative period are included in the global surgical package, as are E/M services related to complications of the surgery that do not require additional trips to the operating room. Post-operative visits unrelated to the diagnosis for which the surgical procedure was performed unless related to a complication of surgery may be reported separately on the same day as a surgical procedure with modifier 24 (Unrelated evaluation and management service by the same physician or other qualified health care professional during a postoperative period)."

Although the statements above indicate that the E/M service is included in the minor procedure, it does not preclude one from reporting a separate E/M service — when it's performed and accurately documented.

According to NCCI, modifier 25 can be appended to an E/M service code when reported with minor surgical procedures or procedures not covered by global surgery rules to indicate that the service is separate and significantly identifiable from other services reported on the same DOS. Because all procedures include pre-, intra- and post-procedural work that is inherent in the procedure, providers must not report an E/M service code for this work.

See what the work descriptor for CPT Code 11100 – Biopsy of skin lesion includes.

Example: NCCI edits when minor procedure code is reported with E/M service code

 Procedure code 
E/M  E/M
 11100 992121 992131 992141
 1140x 992121 992131
 1160x 992121
 17000 992121 992131
 1711x 992121
 1731x 992121

1 = append modifier 25

Note: The same rules above apply to consultation codes 9924x when reported with a procedure.

On the other hand, a procedure with a global period of 90 days is defined as a major surgical procedure. An E/M performed on the same day as a major surgical procedure for the purpose of deciding whether to perform the surgical procedure is separately reportable with modifier 57. 

Other preoperative E/M services on the same DOS as a major surgical procedure are included in the global payment for the procedure and are not separately reportable. NCCI does not contain edits based on this rule because Medicare contractors have separate edits, so check with your local carrier for clarification.

Note: Modifier 57 is the appropriate modifier for an E/M service (related or unrelated to the condition) reported on the same DOS as a major/90-day global period procedure.

For successful, stress-free reporting of E/M service and procedures on the same DOS, one must understand the Global Surgical Package as defined in the CMS Internet Only Manual (IOM) (Claims Processing Manual, Publication 100-04 Chapter 12 (Physicians/Nonphysician Practitioners) Section 40.1 (Definition of a Global Surgical Package).

For more information about coding, email ppm1@aad.org.

Email the Member to Member editor at members@aad.org. 

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