When Should You Bill for an E&M or Clinic Visit and a Procedure on the Same Day?

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Not a week goes by that this author does not receive telephone calls and/or e-mails from people seeking guidance on whether an evaluation and management (E&M) or clinic-visit code can also be billed when a wound care procedure is performed, or reporting that the provider has many claim denials or repayments because an E&M or clinic-visit code was billed along with a minor wound care procedure code. Unfortunately, the responses to these scenarios  are not always what the stakeholder wants to hear. To help shed light on these issues, this edition of Business Briefs features the feedback gathered through interviews conducted over several days with the following wound care reimbursement experts and key opinion leaders who have shared their thoughts on these important topics and areas of confusion:

• Donna Cartwright, MPA, RHIA, CCS, RAC, FAHIMA, senior director of health policy and reimbursement at Integra LifeSciences, Plainsboro, NJ. 
• Sheila Cougras, RN, BSN, CWCN, director of product compliance at Net Health, Pittsburgh, PA. 
• Valerie Rinkle, MPA, president of Valorize Consulting LLC, Medford, OR.

To set the stage for the interview questions, let’s review a few modifier definitions: 

Modifier 24: unrelated E&M service by the same physician or other qualified healthcare professional (QHP) during a postoperative period.

Modifier 25: a significant, separately identifiable E&M service by the same physician or other QHP on the same day of the procedure or other service.

Modifier 57: decision for surgery made within global surgical period.

What follows is an account of the interview with all three professionals: 

Question No. 1: What direction do you provide to wound care physicians, other QHPs, and hospital outpatient provider-based departments (PBDs) when they ask, “When can I bill for an E&M and a procedure on the same day?”

Valerie Rinkle (VR): HIPAA’s Administrative Simplification provisions adopt code sets as part of the required transactions on hospital and professional healthcare claims. The Health Care Procedural Coding System (HCPCS) includes the American Medical Association’s (AMA’s) Common Procedural Terminology (CPT^®) as one level of the HCPCS code set. Hospitals and physicians are required to follow this code set and the guidelines and rules defined as part of the code set. Both the AMA’s CPT manual and the Centers for Medicare & Medicaid Services’ (CMS’) National Correct Coding Initiative (NCCI) edits state that typical pre-procedural E&M services are included or valued in procedure CPT codes and that E&M services are not to be billed in addition to procedure CPT codes unless those E&M services are significant and separately identifiable from the E&M services inherent to and/or needed for the procedure.  

The 2018 NCCI edits state: “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. The fact that the patient is ‘new’ to the provider is not sufficient alone to justify reporting an E&M service on the same date of service as a minor surgical procedure.”

Donna Cartwright (DC): Modifier 25 should only be used when the E&M service is above and beyond the usual pre- and postoperative work of the procedure. Both the medically necessary significant, separately identifiable E&M service and the procedure must be appropriately and sufficiently documented (by the physician or QHP) in the patient’s medical record to support the claim for these services, even though the documentation is not required to be submitted with the claim. Different diagnoses are not required for reporting the E&M service on the same date as the procedure or other service. When medical record documentation supports a separate E&M service, Modifier 25 is added to the E&M code on the claim. When a Medicare Administrative Contractor (MAC) has conducted a specific medical review and has determined, after reviewing the data, that a provider has high use of Modifier 25 compared to other providers, has done a case-by-case review of the records to verify that the use of Modifier 25 was inappropriate, and has educated the provider, the MAC may impose prepayment screens or documentation requirements for that provider. 

Question No. 2: How do you respond when physicians, QHPs, or PBDs ask if they can always bill for an E&M/clinic visit when they see a patient on a first visit and perform a surgical debridement or a selective/nonselective debridement?

VR: Remember that the NCCI edits state: “If a minor surgical procedure is performed on a new patient, the same rules for reporting E&M services apply. The fact that the patient is ‘new’ to the provider is not sufficient alone to justify reporting an E&M service on the same date of service as a minor surgical procedure.”

DC: Most wound care procedures (eg, surgical debridement, selective/nonselective debridement, application of cellular and/or tissue-based products [CTPs] for skin wounds) performed in physician offices and in PBDs have a 0- or 10-day global period and are considered “minor” procedures. For wound care procedures with a 90-day global surgical period, the MACs pay for an E&M service on the day of or on the day before a procedure, if the physician appends Modifier 57 to the E&M code. Modifier 57 indicates that the E&M service resulted in the decision to perform the procedure. 

Question No. 3: Please provide an example of a scenario as to when a wound care physician/QHP should bill for an E&M on the same day that he/she bills for a surgical debridement.

VR: Patient presents for a scheduled wound care visit for a diabetic foot ulcer (DFU) on the right foot. Patient complains of swelling, redness, and pain radiating from a bruise located on a different extremity (left leg). Physician/QHP evaluates new problem and diagnoses early stages of phlebitis. Physician/QHP writes a plan of care to treat the phlebitis and surgically debrides the DFU. 

DC: Surgical debridement performed on DFU of the right foot. New problem identified for a vascular ulcer on the left leg, for which a complete workup was performed and documented. NOTE: Both ulcers were treated, but new location = new problem.  

Question No. 4: Please provide an example scenario as to when a wound care physician/QHP should not bill for an E&M on the same day that he/she bills for a surgical debridement.

VR: Patient presents for scheduled wound care visit. Patient complains of soreness and itching at the wound care site and the inability to perform dressing changes from the last visit to this visit. Physician assesses the wound and notices changes in the wound from the last visit. Physician surgically debrides the wound and reinstructs the patient regarding the importance of changing dressings at the prescribed frequency. 

Question No. 5: Please provide a scenario for which you commonly see wound care physicians, QHPs, and/or PBDs bill an E&M inappropriately.

DC: Using an E&M code with Modifier 25 for taking a history and performing a physical examination on the same day as a toenail debridement, which has a 0-day global period.

Question No. 6: Does your electronic health record (EHR) calculate clinic-visit levels for PBDs?

Sheila Cougras (SC): The PBD may choose to create a unique clinic-visit mapping tool (that is based on the hospital or department’s policy). In that case, the clinic-visit level will appear as an option within the superbill. The user (who has access permission by the PBD) will determine if the clinic-visit level should/should not be submitted on the superbill.

Question No. 7: Does your EHR calculate E&M levels for physicians/QHPs in PBDs and/or in their offices? 

SC: In our EHR, physicians/QHPs can choose to activate a setting that supports the mapping of their history and physical exam documentation to the 1997 documentation guidelines for E&M services as set forth by the AMA. If the setting is activated and if it is appropriate to submit the E&M level, the physician/QHP selects his/her own medical decision-making level of risk when the superbill is opened. 

Question No. 8: Does your EHR always calculate an E&M/clinic-visit level when procedures are performed? If yes, what do you educate the providers to do in that case?

SC: There is no complete automation in our EHR to send both an E&M/clinic visit and procedure code(s) to the superbill.

1. Once configured per client’s choice, certain specified procedure codes are driven from clinical procedure documentation and sent to the superbill.
2. As stated previously, PBDs can choose to use their clinic-visit level mapping tool to determine the clinic-visit level, which is submitted on the superbill if it is appropriate to submit the clinic visit along with a minor procedure. We educate the PBDs to follow their clinic-visit mapping tool policy, the NCCI edit policies, and their various payers’ policies. 
3. As stated previously, physicians/QHPs can choose to have the system use their documentation to map their history and physical exam data elements to the 1997 E&M guidelines. This will generate an option for the physicians/QHPs to select their medical decision-making level of risk and to determine if it is appropriate to submit the calculated E&M level along with a minor procedure on the superbill. We educate the physicians and QHPs to follow the AMA’s 1997 E&M guidelines, the NCCI edit policies, and their various payers’ policies. 

Question No. 9: What is the most important advice you want to give wound care physicians, QHPs, and PBDs about coding and billing for E&M/clinic visits on the same day as a procedure?

VR: Ensure that the E&M is both “significant” in terms of level of effort and import from the E&M work performed as part of the procedure and “separate” from any E&M performed for the procedure. Also, ensure that both these aspects are well documented so that it is unquestionable that Modifier 25 applies to the E&M code billed. 

 DC: Check the NCCI edits, be careful to use Modifier 25 correctly with minor procedures (0- and 10-day global periods), and be sure to use Modifier 57 with E&M decision to perform major surgery (90-day global period) on the same day as the procedure.  

SUMMARY 

Let’s review a few major concepts that were mentioned in these interviews: 

• CMS, NCCI edits, and the Office of Inspector General (OIG) have released guidance documents on this topic, and they all agree. In addition, MACs have claim edits to deny E&M or clinic visits that do not align with the guidance documents.
• Nevertheless, some E&M or clinic-visit claims are incorrectly paid because Modifier 25 is inappropriately appended to the E&M or clinic-visit code. Then, when audits are performed, the physician, other QHP, and/or PBD incurs repayments for inappropriate use of Modifier 25. 
• Global period: All procedures on the Medicare Physician Fee Schedule are assigned a global period of “000,” “010,” “090,” “XXX,” “YYY,” “ZZZ,” or “MMM.” The global concept does not apply to “XXX” procedures. The global period for “YYY” procedures is defined by the MAC that processes practitioner service claims. All procedures with a global period of “ZZZ” are related to another procedure, and the applicable global period for the “ZZZ” code is determined by the related procedure. Procedures with a global period of “MMM” are maternity procedures. 
• Difference between minor and major surgical procedures: NCCI edits state:

“If a procedure has a global period of ‘000’ or ‘010’ days, it is defined as a minor surgical procedure. In general, 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 shall 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. The fact that the patient is ‘new’ to the provider is not sufficient alone to justify reporting an E&M service on the same date of service as a minor surgical procedure. NCCI contains many, but not all, possible edits based on these principles. 

Modifier 25 may be appended to E&M services reported with minor surgical procedures (global period of ‘000’ or ‘010’ days) or procedures not covered by global surgery rules (global indicator of ‘XXX’). Since minor surgical procedures and ‘XXX’ procedures include pre-procedure, intra-procedure, and post-procedure work inherent in the procedure, the provider shall not report an E&M service for this work. Furthermore, Medicare global period rules prevent the reporting of a separate E&M service for the work associated with the decision to perform a minor surgical procedure whether the patient is a new or established patient. If a procedure has a global period of ‘090’ days, it is defined as a ‘major surgical procedure.’ If an E&M is performed on the same date of service as a major surgical procedure for the purpose of deciding whether to perform this surgical procedure, the E&M service is separately reportable with Modifier 57. Other preoperative E&M services on the same date of service as a major surgical procedure are included in the global payment for the procedure and are not separately reportable. For major and minor surgical procedures, postoperative 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. Postoperative 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 E&M Service by the Same Physician or Other QHP During a Postoperative Period’).”

• NCCI procedure-to-procedure (PTP) edits: To verify that PTP edits consider E&M services bundled into some typical wound care procedures, this author researched the NCCI files. The results of one of the searches is displayed in the Table and shows that Code 99213 is bundled into some of the most common minor wound care procedures. NOTE: Not all of the bundled E&M services are listed in the PTP edits. Therefore, wound care professionals should follow the coding and payment guidelines for reporting E&M services and procedures on the same day. 

• Questions that help determine if an E&M or clinic visit should be reported on the same day as a minor procedure:

Why was the patient seen? Did the physician or other QHP address other signs, symptoms, and/or conditions before deciding to perform the minor procedure? Did the complaint or problem stand alone as a billable service?

Did the physician/QHP perform and document the key components of an E&M service for the complaint or problem? Was the E&M of the problem significant and beyond the normal pre- and postoperative work of the minor procedure? Was more than medical decision-making performed? Was the history and physical and medical exam above and beyond that which is already included in the minor procedure code? 

Was the minor procedure scheduled before the patient encounter? NOTE: If yes, it is not medically necessary to bill for an E&M service unless the patient had other medical concerns or problems that were addressed.

Was more than one diagnosis addressed and/or did it affect the treatment and outcome? If not, was the extra work more than usual?

Contrary to popular belief, the following services are not considered a significant, separately identifiable service: calling a patient on the phone, writing new/refill prescriptions, administering medications, and checking blood pressure when the information obtained does not lead to management of a condition or illness.  

• Documentation phrases that may support an E&M and minor procedure on the same day:

“The patient’s condition required” informs the payer of the medically necessary services on the same day that a minor procedure or a service was performed.

“A significant, separately identifiable E&M service above and beyond” the minor procedure should inform the payer that the additional E&M was clearly different from the E&M included in the minor procedure that was performed.

• When your EHR calculates E&M/clinic-visit levels: Some EHRs calculate the E&M/clinic-visit levels based on the documentation submitted in the record. The fact that the EHR calculates the E&M/clinic-visit levels does not necessarily mean that it should be billed in addition to a minor procedure performed that day. The physician, QHP, and PBD should verify: 1) if the calculated E&M/clinic visit is part of the minor procedure performed, or 2) if the calculated E&M/clinic visit represents a significant and separately identifiable E&M service that should be billed with Modifier 25. To report Modifier 25, the physician/QHP should document that on the day he/she performed the minor procedure the patient’s condition required a significant and separately identifiable E&M service that went above and beyond the E&M service that was part of the minor procedure. The physician/QHP can accomplish this by segregating in either a separate note or a separately titled part of the same note the E&M work that was part of the minor procedure and the work that was part of the significant and separately identifiable E&M service. This documentation discipline will help the physician/QHP, coders, and auditors see clearly if any clinical activity was performed above and beyond the E&M work that was part of the minor procedure. NOTE: An E&M/clinic visit separately billed with Modifier 25 must be supported by documentation of history, exam, and medical decision-making to justify, on its own, billing a separate E&M exam on the same day when a minor procedure was performed. Therefore, the physician/QHP should first identify and document the E&M (pre- and postoperative) work that is part of the minor procedure. Then, the physician/QHP should identify and document the E&M clinical activity that was above and beyond the E&M clinical activity affiliated with the minor procedure. Finally, the physician/QHP should apply the usual E&M criteria to the separately identified above-and-beyond activity: If the E&M activity qualifies on its own for any level of E&M, then it should be billed with Modifier 25. 
• Overutilization of Modifier 25: If a provider has a high percentage of usage or overutilization of Modifier 25 compared to other providers, the MAC may enter the provider into the CMS Targeted Probe and Educate program. In addition, the OIG has identified the overuse of Modifier 25. Therefore, wound care physicians, QHPs, and PBDs should exercise caution when reporting an E&M/clinic-visit service with Modifier 25. 

Kathleen D. Schaum oversees her own consulting business and is a founding member of the Today’s Wound Clinic editorial advisory board. She can be reached for consultation and questions at kathleendschaum@bellsouth.net. To contact the interviewees featured in this article, email dcartwright@integralife.com;scougras@nethealth.com; and valerie.rinkle@valorizeconsulting.com.