Fam Pract Manag. 2013 Nov-Dec;20(6):28.
When providing group visits, can we code based on time?
In general, the AAFP advises that you report an E/M code, such as 99213, for a patient seen in a group setting as long as your documentation supports that you provided the key components of the code. In other words, the fact that an E/M service was provided in the presence of other patients does not preclude you from reporting the service as long as all of the necessary elements of the service were provided and documented. The AAFP does not advise coding on the basis of time spent with the group. For more information about coding group visits, see "Coding for Group Visits."
I received a letter from my insurance company stating that I am above the national average for modifier 25 usage. Would you recommend that I stop using modifier 25?
No. Modifier 25 is a necessary component of reporting certain services, such as a preventive medicine service provided in conjunction with an immunization administration. Modifier 25 communicates that a significant, separately identifiable E/M service was provided by the same physician or other qualified health care professional on the same day as another service or procedure.
That said, it is important to recognize when an E/M service goes beyond the pre-service work that is already part of the valuation and payment for a minor procedure. The Medicare National Correct Coding Initiative manual describes a policy that private payers may also follow, which says, “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 should 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.”
One way to evaluate whether your use of modifier 25 is appropriate is to review a group of notes that documented preventive services and minor procedures for which you did not bill a separate problem-oriented E/M code and modifier 25 and then compare them with notes for which you did bill a separate E/M code and modifier 25. In the second group of notes, do you see significant components of E/M work beyond what you documented in the first group of notes? If not, you may want to reevaluate your use of this modifier.
If I re-examine a patient two days after discharge from the hospital for pancreatitis, what is the best code to bill for that office visit?
As long as the visit was not part of the global period for a related procedure that you performed, you should charge the appropriate established patient E/M code (99212-99215). The level of service would be based on a medically necessary history and examination, and the level of medical decision-making indicated by the patient's condition, data reviewed, and risk to the patient between this visit and the next. If you perform any labs in your office, you should bill for those as well.
If you provide transitional care management (TCM) services (99495-99496), the first face-to-face encounter following discharge is covered by the TCM code. However, additional E/M visits within the period of TCM may be separately reported using established patient E/M codes as described above.
Editor's note: Some payers may not agree with the advice given. Refer to current coding manuals and payer policies.
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Send questions and comments to firstname.lastname@example.org, or add your comments below. While this department attempts to provide accurate information, some payers may not accept the advice given. Refer to the current CPT and ICD-10 coding manuals and payer policies.
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