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Many times a patient’s “Oh, by the way …” comment turns an encounter that was scheduled as a preventive medicine visit or a minor office surgery into something more.
Q: How do we bill situations when a patient comes in for a preventive visit and, once in the exam room, informs the physician of additional issues? Does it matter if the conditions are stable? Also, when can we bill an E/M when these types of issues are presented in addition to a procedure performed at that visit?
A: Many times a patient’s “Oh, by the way …” comment turns an encounter that was scheduled as a preventive medicine visit or a minor office surgery into something more. We always need to keep in mind the patient’s expectations for the visit. According to CPT®, separate, significant physician evaluation and management (E/M) work that goes above and beyond the physician work normally associated with a preventive medicine service or a minor surgical procedure is additionally billable. The code that tells the insurer you should be paid for both services is modifier -25.
Used correctly, it can generate extra revenue.
The key is recognizing when your extra work is “significant” and, therefore, additionally billable. While CPT® does not define “significant,” asking yourself the following questions should help lead you to the answer:
If your answers to each of these questions is yes, then you should report the appropriate E/M code with modifier -25 attached as well as the preventive medicine service code or minor procedure code. You can increase the likelihood that the insurer will pay for both services by organizing your note so that documentation for the problem-oriented E/M service is separate from documentation for the preventive service or procedure. You may even want to use headers or a phrase such as “A significant, separate E/M service was performed to evaluate …”
Preventive medicine service with E/M service
The following examples might help clarify the difference between “significant” and “insignificant” services performed in addition to a preventive medicine visit.
A 44-year-old established patient presents for her annual well-woman exam. A complete review of systems is obtained, and an interval past, family and social history is reviewed and updated. A neck-to-groin exam is performed, including a pelvic exam, and a Pap smear is taken. Counseling is given on diet and exercise. Appropriate labs are ordered.
The following situations would not be significant enough to warrant billing a separate E/M service:
The following situations would be considered significant enough to warrant billing a separate E/M service:
Minor surgical procedure with E/M service
CPT code reimbursement for minor surgical procedures includes pre-operative evaluation services such as evaluating the site or problem, explaining the procedure and risks and benefits, and obtaining the patient’s consent. Also, the Centers for Medicare & Medicaid Services (CMS) has clarified that the initial evaluation is included in the reimbursement for a minor surgical procedure and is not separately billable.
However, when you perform an “Oh, by the way” E/M service at the same visit as a procedure and the E/M service requires physician work above and beyond the physician work usually associated with the procedure, the E/M service may be billed in addition to the procedure, with modifier 25 attached to signal to the payer that both services should be paid.
The following examples might help clarify what constitutes “significant” and “above and beyond.”
In the following situation, you should bill the minor surgical procedure code only:
For the following scenarios, an E/M service could be billed in addition to the minor surgical procedure:
Unfortunately, not all insurers will pay you for the separate E/M service even if you code in compliance with CPT rules. Be sure to have your staff appeal any denied or bundled claims. A review of your documentation by the insurer may result in payment for your provider’s work.