Q
Every publication seems to have advice or caution on whether to bill an E&M service on the same day as an office procedure or injection. Could you please provide some examples or guidance on when it is appropriate to add a 25 modifier to an E&M code? I have been asked repeatedly about the following procedures being formed with an E&M service: routine leuprolide acetate injection, cystoscopy, and prostate biopsy.
A
One should always bill for an E&M service on the same day as another procedure if it is medically necessary and over and above the routine pre- and post-care related to the procedure. If the E&M service provided is medically necessary, “significant” (required an identifiable extra amount of time and effort), and “separately identifiable” from the procedure (unrelated to the routine and necessary evaluation/discussion for that procedure), then add the 25 modifier.
As you know, Medicare only accepts the 25 modifier on 0 or 10 global procedures.
If the E&M service is related to the procedure, such as routine evaluation prior to the procedure or the explanation of the findings of that procedure, do not charge.
Here’s how to code an E&M service provided on the same day as the procedures you mentioned:
Leuprolide acetate injection: If the physician provides a medically necessary evaluation and/or treatment, the appropriate level of service can be charged with the attached 25 modifier. The new rules prohibit charging for a 99211 visit.
Cystoscopy: If the patient is evaluated and the decision is made to perform the cystoscopy that day; if there is a significant and separately identifiable discussion of the disease process; or if a another problem is evaluated, discussed, and treated, the E&M service should be charged with a 25 modifier.
If the patient is scheduled for the cystoscopy, and there is no medically necessary reason for a significant and separately identifiable E&M service, do not charge for the E&M service.
Prostate biopsy: In most cases, there may not be a significant and separately identifiable E&M service provided on the same day as a prostatic needle biopsy. However, if a service is performed that fits the criteria outlined in the above example, then it should be charged with a 25 modifier.
Q
We are billing for 51741 and 51798, and 51798 is usually denied as incidental to 51741. I am new to urology, and I’m not sure if a modifier should be appended or if the denial is warranted.
A
Many variables may explain why payment for a procedure is denied. I may not be able to specifically answer your question, because I do not know all the variables. However, I will make a few suggestions about things you should check.
First, look specifically at the payer and the reason the 51798 (measurement of post-voiding residual urine and/or bladder capacity by ultrasound, non-imaging) is being denied. For Medicare, 51798 has the global designation of XXX and therefore should not be included or bundled into another procedure or service. In addition, 51798 has no work value, and since the machine and technology are different, it should be paid.
I would appeal the denials. You mentioned that the 51798 was considered incidental to 51741 (complex uroflowmetry) in this situation. Many practices are being denied because of diagnoses. The required diagnosis vary from state to state.
Urologist Ray Painter, MD, is president of Physician Reimbursement Systems, Inc., in Denver and is also publisher of Urology Coding and Reimbursement Sourcebook
Disclaimer:
The information in this column is designed to be authoritative, and every effort has been made to ensure its accuracy at the time it was written. However, readers are encouraged to check with their individual carrier or private payers for updates and to confirm that this information conforms to their specific rules.
