NEWS ARTICLES

Reporting Multiple Services
By Emily Hill, PA-C

This article is derived from the McMahon Archives. This information may be time sensitive and was archived on 10/1/2001


Getting reimbursed for more than one patient encounter per visit can be difficult. Following the proper coding rules may help.

It is certainly not uncommon to provide more than one service to a patient at a single encounter. Let’s suppose that a young patient presents with complaints of severe headache, fever and generalized malaise. The clinician evaluates the patient and includes meningitis in his differential diagnosis. Based on that possibility, the clinician orders laboratory tests and performs a lumbar puncture. He certainly would like to report all of these services, but has heard that he can only bill for one encounter per day.

Current Procedural Terminology, Fourth Revision (CPT4), and Medicare have similar rules governing the reporting of visits on the same day as a procedure. Other third-party payers may have their own guidelines based on internal payment policies. It is important to remember that following
proper coding rules does not guarantee reimbursement.

Understanding the Rules
According to CPT4, both the evaluation and management (E/M) service and the procedure should be reported if the patient’s condition requires a significant, separately identifiable E/M service. "Significant" implies that the E/M service required some level of history, exam and/or medical
decision-making. "Separately identifiable" means that the visit is distinct from the procedure. In other words, the E/M service should be above and beyond the usual pre- and post-procedure care provided with the lumbar puncture.

CPT4 further instructs the provider to append the –25 modifier to the E/M service to confirm that distinct services were performed. The CPT brief descriptor for the –25 modifier reads, "Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service."

CPT4 also states, in its instructions for using the –25 modifier, "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." Therefore, in the case of this patient, the diagnoses for the E/M service and the lumbar puncture would probably be the same. In other situations, the visit might be prompted by a condition unrelated to the procedure. You
would therefore report all the diagnoses, but link each CPT4 service to the applicable diagnosis code(s) on the insurance claim form.

In general, you report both the E/M service and the procedure if:

  • the decision to perform the procedure was made at the same encounter as the E/M service, regardless of the diagnosis, or
  • the diagnosis for the E/M service was different from the one for the procedure.

Generally, report only the procedure if:

  • the decision to perform the procedure was made at another visit, or
  • the E/M service did not require significant history, a physical and/or decision-making on the day the procedure was performed.


Documenting the Encounter

It is important to clearly document a distinct visit when reporting a procedure on the same day. Since all procedures include some element of patient evaluation, it is necessary to provide evidence of additional services.

Remember, you are indicating two separate elements of "work" for which you are requesting reimbursement. The payer wants to see all the work documented. At a minimum, this means documentation of some level of history, exam, medical decision-making and/or time.

In the event of a review or appeal to the insurance company, it is helpful to physically document separate notes. This does not mean that they have to be on different pieces of paper. For example, simply skipping a space and labeling the procedure portion can distinguish the notes.

Payer’s Response
Medicare will pay for both an E/M service and a procedure on the same day when the E/M service is reported with the –25 modifier. This is regardless of whether single or multiple diagnoses are listed. As with all services, they must be medically necessary for the evaluation or treatment of the patient.

Reimbursement from other third-party payers varies with the insurance company’s payment policy. There are those that follow CPT4 guidelines and will pay for both services if the –25 modifier is attached to the E/M code. Some will pay for both, but only if there are different diagnoses for the E/M service and the procedure. Others may never reimburse for both services on the same day.

Unless you are certain of the payer’s policy, it may be helpful to appeal the denial with adequate documentation of both services. Some payers will pay for both services if there is clear documentation of their need and content.

Checklist for Reporting Multiple Services

  • Only report the visit if it is truly "above and beyond" the work typically associated with the procedure.
  • Make sure that the documentation clearly reflects the distinct nature of both services.
  • Attach the —25 modifier to the E/M service.
  • Monitor the Explanation of Benefits from the payer.
  • Appeal with documentation as appropriate.



Emily Hill, PA-C is President of Hill & Associates, a national health-care consulting firm specializing in coding and compliance for physician practices. Her e-mail address is Emily@codingandcompliance.com.