According to CPT, both an Evaluation and Management (E/M) service and a procedure code can be reported if the patient’s condition requires a significant, separately identifiable E/M service. “Significant” implies that the E/M service required some level of history, exam and/or medical decision-making. “Separately identifiable” suggests that the visit is distinct from the procedure. In other words, the E/M service should be above and beyond the pre- and post-procedure care typically provided. Therefore, simple confirmation of symptoms, explanation of the procedure, signing of consents, and verification of medical information are typically considered inherent in the procedure code and were considered in the value of the procedure.
CPT does not require there be different diagnoses for the E/M service and the procedure to report both codes. After an initial evaluation of a patient presenting with back pain, a decision may be made to proceed with a pain intervention procedure. The same diagnosis would likely apply to the E/M Service and the procedure code. In other situations, the visit might be prompted by a condition unrelated to the procedure. For example, a patient presents for a lumbar epidural steroid injection, but also asks you to evaluate his shoulder pain. You would therefore report both diagnoses, but link each CPT code to the applicable diagnosis code(s) on the insurance claim form.
In general, you report both the E/M service and the procedure if:
- An evaluation and initial decision to perform the procedure was made at the same encounter as the procedure, regardless of the diagnosis, or
- The diagnosis for the E/M service was different from the one for the procedure.
Generally, report only the procedure if:
- The decision to perform the procedure was made at another visit, or
- The E/M service did not require a medically necessary significant history, a physical and/or decision-making on the day the procedure was performed.
When reporting both services, the modifier 25 must be appended to the E/M code to confirm that distinct services were performed. CPT states that a significant, separately identifiable E/M is “defined or substantiated” by documentation that satisfies the relevant criteria for the E/M service. Therefore, it is important to clearly document a distinct visit when reporting a procedure on the same day.
CPT and Medicare have similar rules governing the reporting of visits on the same day as a procedure. Although many third-party payers follow CPT guidelines, others may have their own guidelines based on internal payment policies. It is important to remember that following proper coding rules does not guarantee reimbursement.