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Separately Identifiable Service

  1. Please clarify billing for a separate E/M service on the same day as a procedure.

    There are two different ways to consider use of the modifier 25 with an E/M in the following circumstance:
  1. A patient is seen with complaints of right knee pain. The physician takes a history and performs an examination, also ordering an X-ray of the knee and writing an order for physical therapy. Having evaluated the X-ray, the physician decides that the patient would benefit from a cortisone injection to the knee, and proceeds to administer the injection. In this circumstance, the physician has fully evaluated the condition and used clinical judgment to perform a radiology study and assume orders for a physical therapy regime, supporting a separate E/M service, billed with a modifier 25.
  2. A patient is seen with complaints of right knee pain. The physician takes a history and performs an examination, then proceeds to administer a cortisone injection to the knee. In this situation, the physician’s decision making has been straightforward and uncomplicated by consideration of other information. As such, the service does not warrant billing for a separate E/M service, since no additional work was performed beyond the assessment and injection. Updated 8/29/2017
  1. Scenario of two MDs in the same practice treating the same patient. The first MD evaluates the patient and makes the decision that the patient would benefit from a joint injection. The patient is referred to another provider in the same practice to perform the injection. Would it be appropriate for the second MD to bill another E/M with the injection?

    If both providers are of the same specialty designation, e.g., orthopedics, only one can bill an E/M service on a single DOS. As a reminder, an E/M service done on the same day as a joint injection requires a separate and distinct scope of service than the injection alone. Updated 8/29/2017 

  2. We understand that 99211 cannot be billed with chemotherapy. Do you have guidelines for when an office visit can be billed on the same day as chemotherapy?

    There are two ways in which a separate E/M service (with a modifier 25) may be appropriate:
    1. A patient on chemotherapy is experiencing serious adverse effects, or a new medical condition, requiring full evaluation and reconsideration of dosage and therapy regime. This situation requires key E/M elements such as interval history, examination and medical decision making that may include additional diagnostic testing, and would support a separate E/M service. An example:  the beneficiary states he/she developed a 102o fever last night or perhaps developed severe abdominal pain.  Either of these could be related to the chemotherapy, but would require an appropriate evaluation.
    2. The patient presents with a swollen and bruised left wrist, having sustained a fall the prior day. The provider examines the patient, orders X-rays and prescribes mild pain medication. This service is distinctly separate from the patient’s scheduled visit for chemotherapy, and may be separately billed. Updated 6/9/2017

  3. Please clarify when a podiatrist can bill an E/M visit for a diabetic patient.

    A podiatrist may perform and bill an E/M service for a diabetic patient when the E/M service is for a distinctly separate problem than a procedure scheduled for that date (e.g., diabetic foot care). Updated 6/9/2017
  4. How does NGS define an E/M visit for a separately identifiable service? 

    An E/M service can be considered separately identifiable when it is performed because of a presenting problem or professional service that is different from the original reason for the patient’s visit.
    • Examples of separately payable E/M services:
      • A patient is seen for routine screening colonoscopy. During the post-procedural discussion, the patient complains to the gastroenterologist about frequent heartburn. The physician performs a limited examination and issues a prescription for Protonix.
    • Addressing the patient’s upper GI complaint constitutes a separately payable service.
      • A patient is seen for osteopathic manipulation, but complains of a persistent cough of three orders a chest X-ray and issues a prescription for antibiotics. Addressing the respiratory complaint constitutes a separately payable service.
    • Examples of services that are not separately payable:
      • A patient is seen for screening mammography. Prior to the procedure, the patient’s vital signs are recorded and, following the procedure, the physician discusses the results with the patient and requests a breast sonogram. These services are considered to be part of the mammography service, and not separately payable as an E/M service. Updated 6/9/2017

  5. Can an E/M service be considered separately payable in conjunction with other scheduled procedures, e.g., Yag Laser, medication injection or pacemaker device check?

    An E/M service can be considered separately identifiable when it is performed because of a presenting problem or professional service that is different from the original reason for the patient’s scheduled visit. The examples described here would not appear to support an E/M service. Services such as vital signs or a discussion with the patient relative to the procedure would be included in the payment for the procedure and, unless there a separate problem is address, an E/M service would not appear to be appropriate. Updated 6/9/2017
  6. Why is it that a nurse visit is free of charge, e.g., when administering an injection?

    Payment to the physician for the drug injection includes the nurse’s work in performing the injection, so it is not “free of charge”. Nurses cannot be enrolled as Medicare providers, so services they perform on an incident to basis are included in the physician’s payment on these claims. Updated 6/9/2017
  7. A patient presents to the ED via EMS with trauma.  The ED provider orders the testing, based on clinical presentation; and reads the EKG, FAST echo and ultrasound. 

    The CPT selection is:  99285,25;  93010,26;  93308, 76604, 76775.  They are appropriately documented in the patient chart.  

    The E/M code selection may also be 99291 if the criteria for critical care were met.

    One or more of the tests are being denied as “bundled” to the E/M; though there are no NCCI edits or CPT manual guidance that would prohibit these codes from being billed together and reimbursed separately.  

    Since the ED physician is the first to treat the patient in the emergency department setting and the testing is medically appropriate to evaluate for injury; what is the logic for bundling these codes into the E/M service? 

    CMS IOM Publication 100-04, Medicare Claims Processing Manual, Chapter 13, 100.1 (461 KB) states: The professional component of a diagnostic procedure furnished to a beneficiary in a hospital includes an interpretation and written report for inclusion in the beneficiary’s medical record maintained by the hospital. (See 42 CFR 415.120[a].)

    A/B MACs (B) generally distinguish between an “interpretation and report” of an x-ray or an EKG procedure and a “review” of the procedure. A professional component billing based on a review of the findings of these procedures, without a complete, written report similar to that which would be prepared by a specialist in the field, does not meet the conditions for separate payment of the service. This is because the review is already included in the emergency department E/M payment. For example, a notation in the medical records saying “fx-tibia” or EKG-normal would not suffice as a separately payable interpretation and report of the procedure and should be considered a review of the findings payable through the E/M  code. An “interpretation and report” should address the findings, relevant clinical issues, and comparative data (when available).

    In addition, both the emergency medicine physician and the radiologist/cardiologist will not get paid for the same radiograph or EKG.

    Generally, A/B MACs (B) must pay for only one interpretation of an EKG or X-ray procedure furnished to an emergency room patient. They pay for a second interpretation (which may be identified through the use of modifier 77) only under unusual circumstances (for which documentation is provided) such as a questionable finding for which the physician performing the initial interpretation believes another physician’s expertise is needed or a changed diagnosis resulting from a second interpretation of the results of the procedure.

    When A/B MACs (B) receive only one claim for an interpretation, they must presume that the one service billed was a service to the individual beneficiary rather than a quality control measure and pay the claim if it otherwise meets any applicable reasonable and necessary test.

    When A/B MACs (B) receive multiple claims for the same interpretation, they must generally pay for the first bill received. A/B MACs (B) must pay for the interpretation and report that directly contributed to the diagnosis and treatment of the individual patient. Consideration is not given to physician specialty as the primary factor in deciding which interpretation and report to pay regardless of when the service is performed. Consideration is not given to designation as the hospital’s “official interpretation” as a factor in determining which claim to pay. A/B MACs (B) pay for the interpretation billed by the cardiologist or radiologist if the interpretation of the procedure is performed at the same time as the diagnosis and treatment of the beneficiary. (This interpretation may be an oral report to the treating physician that will be written at a later time.) Updated 6/9/2017

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