A medical assistant is preparing to submit claims for several patients from the previous day. One patient had services that required both an Evaluation and Management (E/M) code and a minor surgical procedure code. The medical assistant notes that the surgical procedure typically has a global period. To ensure proper billing and avoid unbundling issues, what is the most appropriate action the medical assistant should take when submitting this claim?
- ABill the E/M service with modifier -25 and the surgical procedure code separately.
- BOnly bill for the surgical procedure code, as the E/M service is always bundled.
- CBill the E/M service with modifier -59 and the surgical procedure code separately.
- DCombine the charges for both services under a single, higher-level E/M code.
Show answer & explanationAnswer & explanation
Correct answer: A. Bill the E/M service with modifier -25 and the surgical procedure code separately.
When an E/M service is performed on the same day as a minor surgical procedure with a global period, and the E/M service is significant and separately identifiable from the decision to perform the procedure, modifier -25 should be appended to the E/M code. This indicates that the E/M service was distinct and not just inherent to the procedure, allowing both to be reimbursed.
Why the other options are wrong
- B. Bundling the E/M service is often incorrect if it was a distinct service. Only billing the procedure would lead to under-reimbursement.
- C. Modifier -59 is for 'Distinct Procedural Service' and is used to identify distinct *procedures* from other non-E/M services, not to distinguish an E/M from a procedure.
- D. Combining services under a single E/M code is incorrect and constitutes unbundling if the procedure should be billed separately, or downcoding if the procedure value is higher.
CPT Modifier -25
A CPT modifier used to indicate that a physician performed a significant, separately identifiable Evaluation and Management (E/M) service on the same day as a minor surgical procedure or other service.
- Appended to the E/M code, not the procedure code.
- Used when the E/M service goes beyond the typical pre- or post-service care inherent in the procedure.
- Commonly used when the E/M leads to the decision for surgery, or addresses an unrelated problem.
- Crucial for getting both the E/M and the procedure reimbursed.
Memory trick: E/M and procedure on the same day? '25' makes them distinct, not bundled away.