APMA News - November/December 2020 - 22

continued from page 21

also states, " the E/M service may be related to the same or
different diagnosis as the other procedure(s). "
Does this mean we can bill E/Ms along with procedures for
the same diagnosis code? Yes! But the key is in justifying the
separately identifiable E/M with D.O.C.U.M.E.N.T.A.T.I.O.N.,
which seems to be a four-letter word for some physicians.
Always remember the old adage, " if it wasn't documented, it
didn't happen. " What that should say is, " if it wasn't documented correctly, you can't bill it. "
Confused yet? Let's break it down a little further. If the discussion or time spent contributes to the decision to perform the
procedure, that does not automatically count as a separately
identifiable E/M. Regardless of the amount of time spent to
make a decision to perform a procedure (e.g., spending 15
minutes educating a patient about a procedure, complications of the procedure, etc.), the rule remains that any work
toward the decision to perform a procedure is included in the
payment for that procedure.

Example 1
This example addresses a new patient with heel pain who
receives an E/M and a strapping and how to use documentation to support an E/M that was significant and separately
identifiable from the procedure. If the " plan " section of this
note only describes the procedure of a strapping, it does not
support an E/M. When performing procedures with a 0- or
10-day global period, the " triage " of a new problem does not
automatically qualify an encounter for billing an E/M. The
key here is the " M, " which is the medical management component of " E/M " -there has to be a significant medical discussion documented in the plan section of the note that does not
overlap with the report of the procedure. The " plan " must
exhibit a robust paragraph explaining the discussion with the
patient regarding their diagnosis, potential etiologies and
treatment options for this diagnosis, potential risks and benefits of different treatment options, potential advantages and
disadvantages of different treatment options, and how to try
to prevent recurrence. The paragraph should provide evidence that the patient's questions were answered and that a
discussion about treatment options took place. The documentation for the procedure should be its own paragraph and
not overlap with any of the components of the E/M.

Example 2
In this example, an established patient previously had
plantar fasciitis, and their condition resolved. The patient
presents back one year later with a chief complaint of, " my
heel hurts after I get up from rest. " The physician works
them up by performing and documenting a new history
and examination, ordering X-rays, and then diagnoses the
patient with a recurrence of plantar fasciitis. The physician
provides the patient an explanation of this recurrence,
along with insight about what could have been done to
prevent it, as well as current treatment options, and all of
these discussions are documented. A strapping or injec22 APMA News November/December 2020

tion is performed. Because this is a new problem, albeit for
a repeated diagnosis, and a significant and separately identifiable E/M was performed and documented, the E/M
should be submitted with modifier 25. However, if the patient returns after a month or two and the physician decides to strap the patient or provide an injection, an E/M
with a 25 modifier typically would not be justified.

Example 3
This example concerns encounter documentation that might
be used to help justify an E/M for a new patient with plantar
fasciitis who receives an injection. The physician explains plantar fasciitis to this patient and other potential etiologies including foot structure, foot function, unsupportive shoes, etc. The
podiatrist outlines steps that can be taken to try to prevent recurrence, including a discussion of shoegear and the possibility
of rigid, custom, functional orthotics. The physician reviews
stretching exercises with the patient and provides a handout
that details these exercises. The podiatrist and patient discuss
potential long-term treatment options including oral anti-inflammatories, topical anti-inflammatories, ultrasound, physical therapy, and others. The podiatrist explains potential risks,
complications, advantages, and disadvantages of each of these
options. The patient asks three questions and receives answers
to each. The podiatrist spends time talking about which shoe
type custom orthotics would fit best. The podiatrist would
document this significant, separately identifiable medical management, then in a separate paragraph, document a full report
of the injection that was provided to address the acute pain the
patient was experiencing.

Key Billing Pearls
* Only submit an E/M at the same time as a procedure if the
documentation supports no overlap in the work associated
with the E/M and the work associated with the procedure.
A second diagnosis code alone does not automatically qualify the E/M code for a Modifier 25. See item 5 in the Recommended Reading list.
* Never append modifier 25 to CPT 99211. See item 4 in the
Recommended Reading list.
* The 25 modifier added to an E/M code bypasses the CCI
edits, but a failed post payment audit could get very
expensive.
* Document, document, document! n

Recommended Reading
1. NCCI Policy Manual Chapter 1, pp. 18-19; 21.
2. Medicare Claims Processing Manual: Chapter 12, section
30.6.6 section B (pp. 38-39).
3. APMA, 25 Modifier Resources: www.apma.
org/25modiļ¬er.
4. Novitas, Using Modifier 25 to Indicate a Separately
Identifiable E&M Service on the Same Date as Another
Procedure: https://rb.gy/2unlaj.
5. Novitas, Modifier 25 Fact Sheet: https://rb.gy/ns8zjz.


http://www.apma.org/25modifier http://www.apma.org/25modifier https://www.rb.gy/2unlaj https://www.rb.gy/ns8zjz

APMA News - November/December 2020

Table of Contents for the Digital Edition of APMA News - November/December 2020

Contents
APMA News - November/December 2020 - Cover1
APMA News - November/December 2020 - Cover2
APMA News - November/December 2020 - 3
APMA News - November/December 2020 - 4
APMA News - November/December 2020 - 5
APMA News - November/December 2020 - 6
APMA News - November/December 2020 - 7
APMA News - November/December 2020 - Contents
APMA News - November/December 2020 - 9
APMA News - November/December 2020 - 10
APMA News - November/December 2020 - 11
APMA News - November/December 2020 - 12
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APMA News - November/December 2020 - Cover3
APMA News - November/December 2020 - Cover4
APMA News - November/December 2020 - A1
APMA News - November/December 2020 - A2
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APMA News - November/December 2020 - A4
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