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. Lets 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 patients 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
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
diagnosis for the E/M service was different from the one for
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.
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
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
Unless you are certain of the payers 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.
for Reporting Multiple Services
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.
the 25 modifier to the E/M service.
the Explanation of Benefits from the payer.
with documentation as appropriate.
Emily Hill, PA-C is President of Hill & Associates,
a national health-care consulting firm specializing in coding
for physician practices. Her e-mail address is Emily@codingandcompliance.com.