The latest issue of the Medicare Quarterly Provider Compliance Newsletter includes a useful reminder that billing for evaluation and management (E/M) services and pulmonary diagnostic procedures provided to the same patient on the same date often requires the use of a modifier. Failure to use the appropriate modifier may result in getting paid only for the procedure and not the E/M service. Alternatively, it may result in Medicare identifying it as an overpayment and requesting repayment.
The newsletter notes that at least one Medicare recovery auditor conducted an automated review and identified overpayments associated with limited E/M services (identified by Current Procedural Terminology (CPT) codes 99211-99212) billed without modifier 25 on the same date of service as a pulmonary diagnostic procedure (CPT code range 94010-94799). According to the National Correct Coding Initiative Policy Manual for Medicare Services (especially Chapter 11, Section J.2), when a physician performs a pulmonary function study and obtains a limited history and exam, separately coding for an E/M service is inappropriate. However, if the physician performs a significant, separately identifiable E/M service unrelated to the technical performance of the pulmonary function test, the physician may report an E/M service with modifier 25 appended to the E/M code. (You can find the National Correct Coding Initiative Policy Manual in the “Downloads” section of the National Correct Coding Initiative Edits web page.)
As a reminder, you use modifier 25 to indicate that on the day you performed a procedure or service identified by a CPT code, the patient’s condition required a significant, separately identifiable E/M service above and beyond the procedure that you performed. You must document the separate E/M service consistent with CPT E/M services guidelines. Note that the E/M service may be prompted by the symptom or condition for which you provided the procedure and/or other service. As such, you do not need different diagnoses for reporting the E/M services on the same date.
Pulmonary diagnostic procedures, such as spirometry, are commonly done in family medicine in conjunction with another E/M service. When this happens, first ensure that your documentation of the E/M service supports that it can stand alone from the pulmonary function procedure (i.e., the E/M service was above and beyond the limited history and exam typically associated with the procedure). Then, append modifier 25 to the E/M service on your claim. Doing so will go a long way toward ensuring that you are appropriately paid for both services and that Medicare will not demand an overpayment from you somewhere down the road.
– Kent Moore, Senior Strategist for Physician Payment for the American Academy of Family Physicians
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