CODING & DOCUMENTATION

When you provide a significant, separately identifiable E/M service to a patient on the same day of a procedure or other service, you may report the E/M service separately by adding modifier -25, “Significant, separately identifiable [E/M] service by the same physician on the same day of the procedure or other service.” The E/M service may be prompted by the symptom or condition for which the procedure or other service was also provided. The visit should be fully documented to support both the reported level of E/M service and the procedure. It's also helpful to clearly label the procedure portion of the note in case the insurer asks to review the note before authorizing payment.In your example, you referenced code 12001, which is a starred (*) procedure in CPT. According to CPT, a starred procedure is a minor surgical procedure with no associated pre- and postoperative services included in the service. It's important to note that at an initial visit with a new patient, if no significant, separately identifiable service is performed in addition to a starred procedure, code 99025, “Initial (new patient) visit when starred (*) surgical procedure constitutes major service at that visit,” can be reported with the starred procedure. Reporting 99025 indicates that the three key components of a new patient E/M service were not provided, but an abbreviated history was taken and the record was established for the new patient. Insurers vary in their recognition of the starred procedure guidelines and code 99025. For example, Medicare does not distinguish starred procedures from other procedures, and it bundles 99025 with the procedure.

CPT code 99173 may be reported separately when other identifiable services unrelated to this screening test (e.g., preventive medicine services) are provided at the same time. However, 99173 may not be reported separately when acuity is measured as part of a general ophthalmologic service or an E/M service of the eye, because the test is then considered diagnostic rather than screening.Note that a hearing screening test done on calibrated electronic equipment (e.g., 92551, “Screening test, pure tone, air only”) would also be separately reportable when done as part of an annual exam.

Code J0780, “Injection, prochlorperazine, up to 10 mg” may be submitted for a Compazine injection.Be sure to also submit the administration code (e.g., 90782, “Therapeutic, prophylactic or diagnostic injection (specify material injected); subcutaneous or intramuscular”) and note the dose administered. If more than 10 mg of Compazine is injected, record the amount in the units column on the claim form. For example, if the dose is 20 mg of Compazine, submit code J0780 with 2 units of service.

Assuming that you are not providing both the technical (i.e., tracing) and professional (i.e., interpretation and report) components, there are separate codes that can be submitted for providing only the interpretation and report for an ECG (e.g., 93010, “Electrocardiogram, routine ECG with at least 12 leads; interpretation and report only,” and 93042, “Rhythm ECG, one to three leads; interpretation and report only”). These codes can only be reported when you do the interpretation and provide a separate, written report for the patient record. Simply reviewing an automated report and using the information to treat the patient is considered part of the service that the E/M code covers because the data is used to help determine the level of medical decision making.If you are providing the professional and technical components, you should use the appropriate code for the global service (e.g., 93000, “Electrocardiogram, routine ECG with at least 12 leads; with interpretation and report,” or 93040, “Rhythm ECG, one to three leads; with interpretation and report”). Likewise, if you only provide the technical component, you should use the code for the tracing only (e.g., 93005, “Electrocardiogram, routine ECG with at least 12 leads; tracing only, without interpretation and report” or 93041, “Rhythm ECG, one to three leads; tracing only without interpretation and report”).