by Diane E. Zucker, M.Ed., CCS-P

Providing quality care to patients and being paid for the services is often a conflict for payment based on specific insurance program policies and procedures. A new wrinkle in 2022 is the increased denial of E/M services when coded on the same day as a procedure, even with the correctly appended modifier 25.

As we consider the ramifications of these denials, both economically and for patient care, we need to review this process, as allowed by Medicare (CMS) and based on the AMA CPT coding guidelines.

The coding of an E/M service for patient care the requirements to add the modifier -25 is that the E/M service is significant and separately identifiable by the same physician or other qualified health care professional on the same day.  The documentation to support this process would then support the use of modifier -25 on the E/M service.  The definition of what is separately identifiable may be based on the updated E/M guidelines for 2021 would be a service that supported the service based on the identified pertinent history, pertinent exam, with medical decision making reflecting the data, condition risk and treatment risk reflected.

Within the CPT coding guidelines identify for the modifier 25 Significant, Separately Identifiable Evaluation and Management Service by the Same Physician or Other Qualified Health Care Professional on the Same Day of the Procedure or Other Service

It may be necessary to indicate that on the day 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. A significant, separately identifiable E/M service is defined or substantiated by documentation that satisfies the relevant criteria for the respective E/M service to be reported (see Evaluation and Management Services Guidelines for instructions on determining level of E/M service). 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 modifier 25 to the appropriate level of E/M service. Note: This modifier is not used to report an E/M service that resulted in a decision to perform surgery. See modifier 57. For significant, separately identifiable non-E/M services, see modifier 59.

Insurance programs have scrutinized the E/M services on the same day as procedures for a number of years based on several factors. The first factor that has resulted in denials of the E/M with a procedure is the use of only one diagnoses for both services, even though both the AMA CPT coding process and Medicare (CMS) allow for only one diagnoses. The second factor that results in denial of the E/M is the use of a similar or same diagnoses for the procedure that has been coded and billed for prior E/M services.  In this denial process the insurance programs believe that the procedure is a scheduled procedure from a prior visit and assume that the current E/M service as coded and billed would not include any additional or changed information or plan, thus the use of modifier -25 was incorrect. A third factor from some services that require prior authorization (often injection procedures for medication) and that prior authorization process identified the E/M service as related to that prior visit with the assumption by the insurance program that the services as coded and billed with modifier -25 were not supported.

One would not code an E/M with a procedure if the E/M was performed as part of the procedure, as all procedures require the focused history, focused exam and the basic process in medical decision making for the procedure.  If the procedure was scheduled from a prior assessment and at the time of the procedure visit, there was no change in care plan, process or additional risk for treatment identified.  Additionally the E/M may not be appropriate for visits that were requested by a patient that are procedure driven without the level of E/M documented to support this coding.  (Examples - patient request for a specific joint injection, lesion removal).

Each practice should develop specific strategies to manage this process by assessing the specific contacts and identifying the patients it impacts.  The current conflict when the patient care meets the criteria with a clearly separately identifiable E/M service with the procedure and the insurance plans refuse payment, the practice has a number of options:

• Challenge the payment policy by the insurance plans as contradictory to both the AMA CPT coding process and the CMS national policies and procedures (CMS Pub.100-04, chapter 12, section 40.2-40.5; CMS Pub. 100-04, chapter 23, section 30.2 and the specific information through the MLN articles on the CGS web site).
  
  
• If your practice participates with an ACO or other contracting group with insurance programs engage these programs in reviewing these policies on your behalf to modify this policy.
  
  
• When feasible explain to patients the limitations placed on reimbursement for care and services by their insurance program and schedule procedures separate from E/M services (different dates of care).
  
  
• For practices that are out of network with the various insurance plans that have implemented this policy, one should inform patients at the time of care of the potential financial costs of services provided. As an out of network provider the bundling edit process would not be identified as payment is made (in most cases) to the patient with compensation for care is made to the practice directly by the patient.

Actions that would not be appropriate in this circumstance would be making the patient self-pay for the E/M services. The E/M services are considered “bundled” by these insurance plans with this policy and these services are not allowed to be passed on based on the contract between the physician practice and the insurance programs.

Including the procedure into the office visit, up-coding service based on time, would also not be appropriate as one must code the services as documented. If the service is a procedure then the appropriate CPT code for the procedure must be coded based on coding and documentation compliance process.

Patient care is always the priority of each and every provider and this new barrier to reimbursement for care provided is a substantial one that requires acknowledgement and action. The financial impact is real and may require choices in how care is provided or even contract relationships with the identified plans.