Evaluation, management services pose complicated billing questions

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.