Using E&M and a procedural code on the same visit

Last week we discussed the roles of the Current Procedural Terminology (CPT)  Editorial Panel and the Relative Value Scale Update Committee (RUC) in approving codes and relative values. When the RUC reviews a code (e.g., skin testing or pulmonary function testing) they consider whether the procedures may be done on the same day as an Evaluation and Management (E&M) service.

Each CPT code has three RVU components: physician work, practice expense and malpractice used to formulate the value of the code. The RUC looks closely at whether the physician work components of a CPT code may overlap with an E&M code.

In pulmonary function tests and skin testing codes, the RUC has determined there is physician work in each of these codes – separate from the E&M. However, when billed together, the E&M portion has to be documented as a separate identifiable service using a modifier 25 (appended to the E&M code). This is where the confusion exists.

Each year CMS issues the National Correct Coding Initiative Policy Manual for Medicare Services

Chapter 1 deals with general principles of modifier 25 billing. The 2019 Manual (Page 20) states that: “A physician shall not report a separate E&M code with these procedures for the supervision of others performing the procedure or for the interpretation of the procedure.”

However, Chapter 11 goes on to state: “With most "XXX" procedures, the physician may, however, perform a significant and separately identifiable E&M service on the same date of service which may be reported by appending modifier 25 to the E&M code. This E&M service may be related to the same diagnosis necessitating performance of the "XXX" procedure but cannot include any work inherent in the "XXX" procedure, supervision of others performing the "XXX" procedure, or time for interpreting the result of the "XXX" procedure. Appending modifier 25 to a significant, separately identifiable E&M service when performed on the same date of service as an "XXX" procedure is correct coding.”

Chapter 11 (Page 24 and Page 28) pertains to both pulmonary function testing and skin test billing during the same visit as an E&M and states that they may be billed in addition to an E&M.

How big a problem is this?

The Advocacy Council has been aware of procedures and office visits billed on the same day as being an issue with managed care for a number of years. We track inquiries from membership, and it does not appear to be getting worse. Last year these types of issues actually seemed to peak. In 2018 we had 18 inquiries related to E&M being denied - mainly when associated with allergy testing. We have been able to help get reversal of the denials and payment on the majority of these claims – depending on documentation of the E&M as a separate identifiable service.

This went down dramatically after an Advocacy Council webinar on billing for testing last August presented by Alan Goldsobel, MD, FACAAI and Carminia Lopez, Operations Manager for Allergy & Asthma Associates.  We have had only three skin test/E&M coding inquiries to date this year.

However, we are aware of a new policy by Anthem which is vaguely related to denying E&M for a recently billed service or procedure. We are actively working with state medical societies and the AMA to get this policy overturned.

If you are experiencing these types of issues in your practice, be sure to contact the Advocacy Council.

For more information about E&M coding and how/when to bill an E&M visit on the same day as a procedure, view our free College webinar Beyond E&M coding: procedures and more.

Advocacy Issue: 
Billing, Coding & Payments