Evaluation, management services pose complicated billing questions

August 1, 2006

Evaluation and management (E/M) services continue to be one of the most complicated issues in dermatologic billing. Whether it's how to document properly based on the level of care provided or getting paid for the various types of E/M services when procedures are billed on the same date of service, it all seems to be an uphill climb.

In this issue, I will address a myriad of questions that never seem to go away. I hope some of the answers will eliminate my readers' questions and concerns once and for all.

Q When billing an E/M visit on the same day as a procedure, I know that I must use modifier 25 on the visit code to assure payment. It is my understanding that the definition of "significant, separately identifiable" means that I must have a different diagnosis for the E/M visit. It cannot be the same as that of the procedure. My old office manager told me never to bill an E/M visit with a procedure if there is only one ICD-9 code. I must have a separate diagnosis for the E/M visit. Frequently, especially for new patient visits, my dermatologist has to spend a lot of time with the patient before he can even determine what procedure is necessary. I really feel he should be paid for both. Is there any way around that rule? New Rules

CPT makes it very clear that, whether you are billing a new patient or a visit for an established patient, you do not need two diagnoses in order to bill an E/M with a procedure. The record, however, should document an important, notable, distinct correlation with signs and symptoms to make a diagnostic classification or demonstrate the distinct problem.

Q In looking at Medicare's Correct Coding Initiative, I see office visits listed in the second column, which means that the visits are bundled into other services (especially 90772). Does this mean that I must attach a 59 modifier to the office visit in order to get paid? I thought modifier 59 was only for procedures and services. Was I wrong in my assumption? CCI in Calif.

A Dear CCI:
I got totally confused on that myself. I had to check with the American Academy of Dermatology to get clarification and they said that in that instance, you would use a 25 on the E/M visits, not 59. Modifier 59 should never be attached to E/M visits.

Q I understand that Medicare will pay a new patient visit or consultation, billed on the same date as a procedure, even if modifier 25 is not attached to the E/M service. Is that correct? We have received various bits of conflicting information and don't know whose advice is correct. I thought I would go to the source for the final say - you! Conflicted

A Dear Conflicted:
The answer is that most Medicare carriers and some commercials do pay for an E/M visit or consultation without the appending of modifier 25. However, they are so inconsistent that I usually advise billers to just put the modifier 25 on all E/M visits if there is a procedure performed on the same date of service.