Sheep are thought of as nervous animals, a good target for predators. You do not want to be a sheep. Unfortunately, many electronic health record (EHR) programs make you a target for audits and requests for the return of payments for a variety of reasons. Although you likely are aware of the uses of modifier -25, it is the abuses—either intentional or accidental—that can bring an audit your way. The use of modifier -25 was previously reviewed in Cutis.1 Despite the availability of this excellent review, I have found that there is still great confusion about both the use of modifier -25 and the selection of the correct evaluation and management (E&M) code when used.
When to Bill for E&M
Based on recent discussions with colleagues in the New York area who have been audited, an easy way to bring on a request for medical records is to report an E&M 100% of the time with a procedure. In these instances, every single E&M was performed on the same visit as a dermatologic procedure, most commonly biopsies(Current Procedural Terminology [CPT] code 11100, 11101) and premalignant destructions (CPT code 17000, 17003, 17004), which is in contrast with typical practitioners who perform an E&M approximately 70% of the time (RUC rationale; American Medical Association RBRVS Data Manager; May 12, 2016). One circumstance involved the reporting of E&M services 100% of the time when performed during the same visit as Mohs micrographic surgery (CPT code 17311–17315), a surprising frequency considering that the typical same day use of a code for this procedure with an E&M in the Medicare population is less than 25%.
According to the National Correct Coding Initiative Policy Manual for Medicare Services, procedures with a global period of 90 days are defined as major surgical procedures,2 which only include adjacent tissue transfers and grafts for dermatology. If an E&M is performed on the same date of service as one of these procedures to decide whether to perform the procedure, the E&M can be reported separately using modifier -57. Other preoperative E&M services provided on the same date of service as a major surgical procedure are included in the global payment for the procedure and are not reported separately.2
All other procedures dermatologists perform generally are considered minor, which are defined as having a global period of 0 or 10 days. Because the decision to perform a minor procedure is included in the payment for the procedure, E&M services should not be reported separately from the minor procedure. However, “a significant and separately identifiable E&M service unrelated to the decision to perform the minor surgical procedure is separately reportable with modifier 25. The E&M service and minor surgical procedure do not require different diagnoses. If a minor surgical procedure is performed on a new patient, the same rules for reporting E&M services apply.”2
These guidelines seem straightforward, but as with so much else where the government is involved, the devil is in the details. When making coding decisions, you may consult the documentation guidelines from either 19953 or 1997,4 which are available for download on the Centers for Medicare & Medicaid Services (CMS) website (https://www.cms.gov/outreach-and-education/medicare-learning-network-MLN/MLNedwebguide/emdoc.html). The 1995 guidelines are less empiric and offer more flexibility, while the 1997 guidelines rely on number of “bullets” as examination elements.
According to the 1995 documentation guidelines, the levels of E&M services are based on 4 types of examination that are defined as follows: (1) problem focused, a limited examination of the affected body area or organ system; (2) expanded problem focused, a limited examination of the affected body area or organ system and other symptomatic or related organ system(s); (3) detailed, an extended examination of the affected body area(s) and other symptomatic or related organ system(s); and (4) comprehensive, a general multisystem examination or complete examination of a single organ system.3 Detailed history is the fuzziest part of the coding universe. Some insurers take an approach that you need to examine 2 to 7 organ systems and 4 distinct lesions in 4 body areas, which is discussed in audit tools available from some Medicare intermediaries (Advancing the Business of Healthcare forum; April 10, 2014). As a result, the 12-bullet examination from the 1997 documentation guidelines may be more suitable for a new level 3 or established level 4 visit. For a comprehensive examination, the 1995 criteria allow for a complete examination of a single organ system such as the full-body skin examination with the patient completely undressed, which is medically necessary in our melanoma patients.