8. Do not abuse modifier 25.
Some providers bill encounter codes improperly appended with modifier 25 Significant, separately identifiable evaluation and management service by the same physician or other qualified healthcare professional on the same day of the procedure or other service. Modifier 25 is proper only when a separately identifiable E/M service is performed at the same encounter as another service. The E/M service can relate to the procedural service, but it must represent service above and beyond what is normally included in the procedure. For example, an established patient presenting for routine cryotherapy of warts would probably not qualify for an E/M service. However, a new patient presenting for the same problem would need an E/M service to take the initial history and perform an initial physical examination.
9. The necessity of ancillary testing is clear.
When testing or procedures are part of the encounter, the reason and necessity for these items must be clearly documented or intuitively obvious to medical personnel. A Pap smear is understandably part of a routine gynecological examination and does not need special documentation. However, in many cases, it may take a few words of explanation to clarify why certain tests were included in the encounter. While “rule out” diagnoses are not valid to submit for professional billing purposes, they can be used in the text of the record to explain the need for testing.
10. Set your watch for time-based encounters.
When time-based billing is used to report an E/M service, the documentation should justify the time spent, precisely. Documentation should include time spent performing non-face-to-face services the day of the visit. For all but office and other outpatient E/M services, documentation must indicate that counseling and/or coordination of care dominated the service.
These 10 commandments cover the most important facets required for precise E/M coding. Adhering to these principles will help ensure that your practice’s documentation and coding are sound and able to withstand payer scrutiny.
Originally Published On: AAPC Forum
Photo courtesy of: Deposit Photos
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