After years of Litigation, E/M Denials Persist

Notwithstanding years of litigation and multi-million dollar settlements, many healthcare providers continue to experience inappropriate evaluation and management service (“E/M”) denials. Earlier today, I spoke with a provider who had a well-founded complaint regarding his denials, so I want to take a minute to quickly review the basics.

E/M is a visit or consultation provided by a healthcare provider. Each E/M can be identified by a unique Current Procedural Terminology (“CPT”) code such as 99203, which identifies an outpatient visit with a new patient presenting with symptoms that are of moderate severity.

As a general rule, payers will not provide separate reimbursement for E/M services that are directly related to and necessary for your performance of the procedure on the same day as the E/M for which you are obtaining reimbursement. Nevertheless, as described below by Medicare, E/M is reimbursable in certain scenarios if modifier 25 is properly utilized. Specifically, Medicare explains:

Modifier 25 is used to facilitate billing of evaluation and management services on the day of a procedure for which separate payment may be made. It is used to report a significant, separately identifiable evaluation and management service performed by the same physician on the day of a procedure. The physician may need to indicate that on the day a procedure or service that is identified with a CPT code was performed, the patient’s condition required a significant, separately identifiable evaluation and management service above and beyond the usual preoperative and postoperative care associated with the procedure or service that was performed.

When you use modifier 25, you should make certain that your records support the separate and distinct nature of the services. Naturally, your records should clearly document history, examination and decision-making.

While your medical notes need not be submitted with the claim (unless you are in a pre-payment audit), they will be needed in the event of a post-payment audit of your use of modifier 25. If you are audited, comprehensive medical notes will likely ensure that you can retain your reimbursements and will prevent the payer from broadening the scope of its audit.

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