Evaluation and management (E&M) services
By C. Matthew Hawkins, MD Summer 2018
Q: What documentation is necessary to report evaluation and management (E&M) services that are performed on the same day a patient undergoes a subsequent procedure?
A: There are a number of factors to consider when determining whether or not clinical work performed on the same day as a procedure can be reported with separate E&M codes. It is important to know that some E&M work is already part of the value of the CPT codes used to report procedures Basic pre- and postprocedural work, such as reviewing images, pre-procedure physical exam (focused heart and lung, focused exam to document baseline function in anticipation of potential procedural complications), consent, and discussing results with the patient and their family are already inherent to the CPT codes used to report the procedural work. The time required to complete this pre- and postprocedural work is derived from RUC survey data collected from SIR members. If a decision to treat has already been made (assumed if a patient is already scheduled for a procedure), separate E&M work cannot be reported.
However, if an IR is asked to evaluate a patient and the decision is made to perform a procedure on the same day, appropriate E&M documentation does allow for separate reporting of that E&M service.
There must be adequate documentation to support a separate, distinguishable service from that which is included in the pre-procedural work included in the procedural CPT code. Most importantly, this documentation must include the medical decision making that led to the same-day procedure.
When providing distinguishable E&M service for a 0- to 10-day global procedure (which represents the vast majority of IR procedures), a modifier -25 should be appended to the reported E&M code. If the procedure is a 90-day global code, a modifier -57 should be appended, instead.
You should be aware that both the National Correct Coding Initiative (NCCI) and the Office of the Inspector General (OIG) have separately identified the use of modifier -25 as an example of inappropriate upcoding. Thus, providing adequate, thorough documentation is paramount in these settings to ensure both payment and compliance.
Disclaimer: SIR is providing this billing and coding guide for educational and information purposes only. It is not intended to provide legal, medical or any other kind of advice. The guide is meant to be an adjunct to the American Medical Association’s (AMA’s) Current Procedural Terminology (2017/CPT®). It is not comprehensive and does not replace CPT. Our intent is to assist physicians, business managers and coders. Therefore, a precise knowledge of the definitions of the CPT descriptors and the appropriate services associated with each code is mandatory for proper coding of physician service.
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