Based upon an article that is posted within The American Institute of Healthcare Compliance website, it is important to note that the OIG is Auditing for Abusive Dermatology Claims.
The Office of the Inspector General (OIG) is auditing dermatologists for billing an E/M service on the same date of service that a minor surgical procedure (ie. postoperative global period of 0 or 10 days) is performed. Medicare only covers Evaluation & Management (E/M) services on the same day as a minor procedure if a physician/surgeon performs a significant and separately identifiable E/M service that is unrelated to the decision to perform the minor surgical procedure. In order to bypass the CCI edits or the Correct Coding Initiative edits and bill for the E/M service and the minor surgical procedure/CPT code on the same date of service, the 25 modifier needs to be appended to the E/M service. The 25 modifier is defined as the following: SIGNIFICANT, SEPARATELY IDENTIFIABLE E/M SERVICE BY THE SAME PHYSICIAN ON THE SAME DAY OF THE PROCEDURE OR OTHER SERVICE. It may be necessary to indicate that on the day a procedure or service identified by a CPT code was performed, the patient’s condition required a significant, separately identifiable E/M service above and beyond the other service provided or beyond the usual pre and postoperative care associated with the procedure that was performed. A significant, separately identifiable E/M service is defined or substantiated by documentation that satisfies the relevant criteria for the respective E/M service to be reported. The E/M service may be prompted by the symptom or condition for which the procedure and/or service was provided. As such, different diagnoses are not required for reporting of the E/M services on the same day. This circumstance may be reported by adding modifier 25 to the appropriate level of E/M service.
In 2019, the OIG found that approximately 56 percent of dermatologists' claims with an E/M service also included minor surgical procedures (such as lesion removals, destructions, and biopsies) on the same day. This may indicate abuse whereby the provider used modifier 25 to bill Medicare for a significant and separately identifiable E/M service when only a minor surgical procedure and related preoperative and postoperative services are supported by the beneficiary's medical record. This is very significant as this alleged abuse took place more than 50% of the time!
Through investigation, the OIG will determine whether dermatologists' claims for E/M services on the same day of service as a minor surgical procedure complied with Medicare requirements.
If this article and investigation applies to dermatologists, why am I making podiatrists aware of this issue in this forum? Dermatologists are among the leaders in the medical profession that perform minor surgical procedures (ie. biopsies) on the same date of service that the patient is seen for a specific problem. Our profession, podiatry carries out the same task. Don’t we perform E/M services on the same date of service as a minor surgical procedure? Of course we do! Examples would be injections, nail avulsions, matrixectomies, biopsies and most of all “At Risk,” Routine Foot Care and the debridement of symptomatic mycotic nails.
Based upon the above, I strongly believe that it is imperative to make sure that the documentation in the medical record for the date of service in question firmly supports the billing of an E/M service and a minor surgical procedure on the same date of service.
There are three appropriate ways to utilize the 25 modifier to indicate a significant, separately identifiable E/M service as long as the documentation within the medical record for that specific date of service is beyond reproach.
1. An INITIAL E/M service CAN be billed when performed on the SAME date of service as a minor surgical procedure code. The diagnosis code for the INITIAL E/M service and the diagnosis code for the minor surgical procedure CAN be the SAME. Why can they be the same? You have never seen this patient before. It is a new patient. Office and other outpatient E/M services include “a medically appropriate history and/or physical examination, when performed.” “Medically appropriate” means that the physician or other qualified healthcare professional reporting the E/M service determines the nature and extent of any history or exam for a particular service. Remember that E/M code selection does not depend on the level of history or exam. However, in order to determine the diagnosis that needs to be addressed either medically or surgically and of course, for medical/legal reasons, isn’t it important to perform an appropriate history and examination in order to address both of these issues? Of course it is! So, based upon a medically appropriate history and examination, the physician is able to diagnosis the patient. This shows Medical Necessity. If this diagnosis code leads to the performance of a minor surgical procedure, then the diagnosis code for the E/M service and the procedure can be the same. If the process was so simple that the patient, for example came in with heel pain and the physician just administered a cortisone injection into the plantar fascia then of course, the E/M service would be moot and not billable. Only the minor surgical procedure, the injection warrants being billed.
2. AN ESTABLISHED patient E/M code CAN be billed when performed on the same date of service as a minor surgical procedure code. The diagnosis code for the established E/M service MUST BE DIFFERENT from the diagnosis code for the minor surgical procedure. There can be absolutely, positively NO CORRELATION between the E/M service and the minor surgical procedure.
3. If an established patient is seen for a NEW problem that has never been evaluated for previously (ie. never mentioned, never examined, never treated) and a minor surgical procedure is performed on the SAME date of service, then not only can BOTH the established patient E/M service code AND the minor surgical procedure code be billed for, but the diagnosis code for the E/M service and the diagnosis code for the minor surgical procedure can be the SAME. Of course the entire scenario needs to be completely documented in the medical record.
For years, the number one reason that podiatrists are audited and fail the audit is the inappropriate use of the 25 modifier. I have opined on this issue for what appears to be forever. I hope that the people that have heard me lecture took what I said seriously. Based upon the fact that the Department of Health and Human Services has paid out an enormous amount of money in an attempt to provide financial assistance to medical practices during the pandemic, it was just a matter of time before they would come up with a plan to recoup a fairly significant portion of this money. If dermatologists are inappropriately billing an E/M service and a minor surgical procedure on the same date of service more than 50% of the time, do you really think that the profession of podiatry is doing the same at a much lower, acceptable rate? Based upon my experience, I suspect not.
Michael G. Warshaw
DPM, CPC
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