Medical groups report modifier
25 (Significant, separately identifiable E/M service) a whole lot, with claims tagged with the modifier returning
north of $4 billion in payments annually. Ensure your modifier coding is accurate, and that your documentation backs it up, to keep revenue coming in.
A recent issue of
Part B News highlights four tips that your practice can incorporate to avoid denials on your same-day E/M claims. Julia Kyles, CPC, shared a series of tips gleaned from a recent webinar, “Reduce Physician E/M Denials with Compliant Modifier 25 Reporting,” led by Betty A. Hovey, BSHAM, CCS-P, CDIP, CPC, COC, CPMA, CPCD, CPB, CPC-I, owner of Compliant Health Care Solutions.
Here's a key one:
Clearly document the clinical rationale for the minor procedure and the E/M visit. Make sure the documentation for the procedure doesn’t overshadow the E/M visit, Hovey warned. The documentation needs to state the reason for the E/M visit, especially when the diagnosis for the minor procedure and the E/M visit are the same. For example, consider a scenario when the patient has actinic keratosis (AK) and the provider is treating some with cryotherapy and some with medication. “Make sure that you’re saying, ‘Well, I did this minor procedure, but since the patient still had other AKs in other areas of the body and I’m treating those with a medication, not with cryotherapy, so we have this separate E/M here,’” Hovey said.
And another:
Highlight the separate E/M visit. For example, the patient might bring up a new complaint during the visit for a minor procedure, which is known as the “oh by the way” visit, Hovey said. A change in the condition that is being treated could also prompt a separate E/M visit. For example, the patient has been coming in for steroid injections for joint pain and says it seems to be aggravated or getting worse. As a result, the provider has to reconsider their treatment plan and perhaps consider more diagnostic tests or other additional work. “Now you are showing that there is medical necessity to do a separate E/M service,” Hovey explained.
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