An established patient returned for a scheduled diagnostic cystoscopy. Following the cystoscopy, I spent a considerable amount of time discussing the patient’s incontinence and suggested treatment. I checked the evaluation and management service, with the –25 modifier, in addition to the cystoscopy. The compliance department stated that I could not charge for the E/M because it was included in the global of the procedure. Can I charge for the E/M and the cystoscopy?
If you appropriately documented your service, the answer is yes.
Explaining to the patient the findings of the procedure is included in the global of that procedure. However, discussing the disease/problem and a suggested treatment plan is not in the global and therefore meets a portion of the definition of the –25 modifier as being “separately identifiable,” even if the diagnosis for the cystoscopy and the E/M service is the same.
Since you spent a considerable amount of time, it sounds like your discussion was “significant,” satisfying the second requirement for the use of the –25 modifier. If you documented the specific time spent in discussion and the topics that you covered during the discussion, you should charge the appropriate E/M code based on time.
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If the specific time spent discussing the disease and the appropriate treatment was not documented, then be sure that your documentation meets the criteria (history, physical examination, and medical decision-making) separate from any criteria performed to make sure the patient was prepared and able to have the procedure.
We have recommended strongly that you separate the documentation of the procedure from the E/M service if possible. This can be done by separating the E/M portion of the note from the procedure in a separate paragraph or by opening a second encounter within the patient record. The separation of notes is not required by CPT but helps clearly differentiate the two services to the payer and your compliance department.
Send coding and reimbursement questions to Ray Painter, MD, and Mark Painter c/o Urology Times, at [email protected].
Questions of general interest will be chosen for publication. 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.