EVALUATION AND MANAGEMENT (E/M)

Transcription

1 Mdifiers Billing Guide Effective fr claims with dates f service n and after January 1, 2008, Medicare cntractrs shall have discretin t establish lcal cverage plicies fr thse indicatins nt included in NCD NHIC has established Lcal Cverage Determinatin (LCD) L17753 fr ESA administratin. This LCD can be fund at Denials f claims fr ESAs are based n reasnable and necessary determinatins established by NCD A prvider may have the beneficiary sign an Advanced Beneficiary Ntice, making the beneficiary liable fr services nt deemed reasnable and necessary and thus nt cvered by Medicare. Fr additinal infrmatin: CMS Change Request 5699 at CMS Change Request (CR) 5480 at CMS Pub , Chapter 8, sectin EVALUATION AND MANAGEMENT (E/M) Reprt the mdifiers listed belw n E/M cdes nly. -21 Prlnged Evaluatin and Management Services: When the face-t-face r flr/unit service(s) prvided is prlnged r therwise greater than that usually required fr the highest level f evaluatin and management service within a given categry, it may be reprted by adding mdifier 21 t the evaluatin and management cde number. A reprt is required. CMS has classified this mdifier as infrmatinal nly fr which n additinal reimbursement is allwed. Althugh the descriptin indicates a reprt may be apprpriate, please d nt submit any reprts. -24 Unrelated evaluatin and management service by the same physician during the pstperative perid Mdifier -24 was intended fr use with the E/M service r eye exam cdes perfrmed during the pstperative perid fr a reasn(s) unrelated t the riginal majr r minr surgery. It is nt t be used fr medical management f a patient by the surgen fllwing surgery. Use f the -24 mdifier is apprpriate with CPT cdes and NHIC, Crp. 22 June 2009 REF-EDO-0058 Versin /12/09 Message fr internal use nly: The master cpy f this dcument is stred in the NHIC ISO Dcumentatin Repsitry. Any ther cpy, either electrnic r paper, is an uncntrlled cpy and must be deleted r destryed when it has served its purpse.

2 Mdifiers Billing Guide Services submitted with mdifier -24 must be sufficiently dcumented in the medical recrd t establish that the visit was unrelated t the cnditin fr which the surgery was perfrmed. D nt submit the dcumentatin unless requested t d s. Append mdifier -24 t the E/M cde perfrmed during a pre r pstperative perid f a prcedure perfrmed by the same physician, but which is unrelated t the majr r minr surgical prcedure perfrmed. When submitting mdifier 24 with cdes ( ), dcumentatin that the critical care was unrelated t the specific anatmic injury r general surgical prcedure perfrmed must be submitted. Examples f Supprting Dcumentatin: ICD-9-CM cde(s) that are clearly unrelated t the surgery Dcumentatin clearly explaining why the visit is unrelated t the surgery. Dcumentatin indicating immunsuppressive therapy fr rgan transplants. T determine the glbal perid f a surgery, refer t the Medicare Physician Fee Schedule database (MPFSDB). Access the database directly frm the CMS Website at There is a Glbal Surgery Perid Calculatr available n the NHIC website under Self-Service Tls that will assist in determining the end f the glbal perid fr majr surgeries. -25 Significant, Separately Identifiable Evaluatin and Management Service by the Same Physician n the Same Day f the Prcedure r Other Service: It may be necessary t indicate that n the day a prcedure r service identified by a CPT cde was perfrmed, the patients cnditin required a significant, separately, identifiable E/M service abve and beynd the ther service prvided r beynd the usual preperative and pstperative care assciated with the prcedure that was perfrmed. A significant, separately identifiable E/M service is defined r substantiated by the dcumentatin that satisfies the relevant criteria fr the respective service t be reprted. The E/M service may be prmpted by the symptm r cnditin fr which the prcedure and/r service was prvided. As such, different diagnses are nt required fr reprting f the E/M services n the same date. Dcumentatin in the patients medical recrd must supprt the use f this mdifier. Nte: This mdifier is nt used t reprt an E/M service that resulted in a decisin t perfrm majr surgery (i.e., thse with a 90-day fllw-up perid). See mdifier -57. Fr significant, separately identifiable nn E/M services, see mdifier 59. NHIC, Crp. 23 June 2009 REF-EDO-0058 Versin /12/09 Message fr internal use nly: The master cpy f this dcument is stred in the NHIC ISO Dcumentatin Repsitry. Any ther cpy, either electrnic r paper, is an uncntrlled cpy and must be deleted r destryed when it has served its purpse.

3 Mdifiers Billing Guide Example: N supprting dcumentatin is required with the claim when this mdifier is submitted. Hwever, the patients medical recrds must cntain infrmatin t supprt the use f mdifier - 25 and be available upn request. The fllwing are the exceptins: This mdifier shuld nt be submitted with E/M cdes that are explicitly fr new patients nly: 92002, 92004, , , , and These services are nt cnsidered part f the glbal surgical plicy. Use mdifier -25 n initial hspital visit ( ), an initial inpatient cnsultatin ( ) and a hspital discharge service (99238 and 99239), when billed fr the same date as an inpatient dialysis service. Use mdifier -25 when preperative critical care cdes ( ) are billed within a glbal surgical perid. Reprting these E/M services with mdifier -25 indicates that they are significant and separately identifiable. Dcumentatin that the patient is critically ill and requires the cnstant attentin f the physician, and the critical care is unrelated t the specific anatmic injury r general prcedure perfrmed must be submitted. Use mdifier -25 n an E/M service when perfrmed at the same sessin as a preventive care visit when a significant, separately identifiable and medically necessary E/M service is perfrmed in additin t the preventive care. The E/M must be carried ut fr a nn-preventive clinical reasn, and the ICD-9-CM cde(s) fr the E/M service shuld clearly indicate the nn-preventive nature f the E/M service. Use mdifier -25 if the decisin fr surgery is made n the same day as a minr surgery (i.e., thse with a 0 r 10- day fllw-up perid) if the decisin is made during an E/M service the day f surgery. This mdifier may be used t indicate that an E/M service was prvided n the same day as anther prcedure that wuld nrmally bundle under Natinal Crrect Cding Initiative (NCCI). In this situatin, mdifier -25 signifies that NHIC, Crp. 24 June 2009 REF-EDO-0058 Versin /12/09 Message fr internal use nly: The master cpy f this dcument is stred in the NHIC ISO Dcumentatin Repsitry. Any ther cpy, either electrnic r paper, is an uncntrlled cpy and must be deleted r destryed when it has served its purpse.

4 Mdifiers Billing Guide the E/M service was perfrmed fr a reasn unrelated t the ther prcedure. Access the CMS website fr the Natinal Crrect Cding Initiative at ge. D nt use mdifier -25 n a surgical cde ( ) since this mdifier is used t explain the special circumstance f prviding the E/M service n the same day as a prcedure. NOTE: The mst cmmn cause fr claim denial f an unrelated E/M service billed n the same day as anther prcedure r during the pst perative perid fr a nn-surgery related reasn is due t the missin f mdifier -25. Multiple Mdifiers May Apply When a visit ccurs n the same day as a surgery with 0 glbal days and within the glbal perid f anther surgery AND the visit is unrelated t bth surgeries, mdifiers 24 and 25 must be submitted. Fr example: A patient cmes t the ffice fr cnsultatin and an endscpic prcedure is perfrmed. The results require immediate perfrmance f majr surgery the next day. The cnsultatin wuld require the use f mdifier -24 fr the endscpic prcedure, and -25 fr the majr surgery perfrmed the next day. -57 Decisin fr Surgery: An evaluatin and management service that resulted in the initial decisin t perfrm the surgery may be identified by adding mdifier -57 t the apprpriate level E/M service Nte: Mdifier Billing -57 Tips: is nly used with evaluatin and management services perfrmed within 24 hurs f a majr prcedure. The glbal perid fr a majr prcedure includes the day befre, the day f, and the 90 days immediately fllwing the prcedure. NHIC, Crp. 25 June 2009 REF-EDO-0058 Versin /12/09 Message fr internal use nly: The master cpy f this dcument is stred in the NHIC ISO Dcumentatin Repsitry. Any ther cpy, either electrnic r paper, is an uncntrlled cpy and must be deleted r destryed when it has served its purpse.

5 Mdifiers Billing Guide E/M services n the day befre the prcedure, the day f the prcedure, and within the 90-day pstperative perid are generally nt payable. Only initial services and services unrelated t the prcedure perfrmed may be cnsidered fr payment. D nt use Mdifier -57 with minr surgeries (zer- t 10 day pstperative perid). See Mdifier 25. N supprting dcumentatin is required with the claim when submitted but must be included in the patients medical recrd and available upn request. Fr additinal infrmatin: refer t the General Surgery Billing Guide n the NHIC website at CMS Internet Only Manual (IOM) Pub , Chapter 12 T determine the glbal perid f a surgery, refer t the Medicare Physician Fee Schedule database (MPFSDB)n the CMS Website: EYE Use the apprpriate mdifier fr additinal infrmatin when billing eye prcedures. -AP -LS -VP Determinatin f refractive state was nt perfrmed in the curse f diagnstic phthalmlgic examinatin May be submitted with CPT cdes 92002, 92004, and Because this mdifier is infrmatinal nly, submit in the last mdifier psitin after any ther apprpriate mdifiers. FDA- mnitred intracular lens implant Submit this mdifier n physician claims fr eye surgery with IOL implants Aphakic patient Submit this mdifier with Evaluatin and Management (E/M) cdes r eye exam cdes t indicate that the patient is aphakic. This mdifier is infrmatinal nly. The fllwing mdifiers are ften used fr prcedures r diagnstic tests that may be bundled when perfrmed n the same eye(s): -E1 Upper left eyelid -E2 Lwer left eyelid -E3 Upper right eyelid -E4 Lwer right eyelid NHIC, Crp. 26 June 2009 REF-EDO-0058 Versin /12/09 Message fr internal use nly: The master cpy f this dcument is stred in the NHIC ISO Dcumentatin Repsitry. Any ther cpy, either electrnic r paper, is an uncntrlled cpy and must be deleted r destryed when it has served its purpse.