An Evaluation and Management (E/M) service is a medical encounter in which a healthcare provider evaluates a patient’s condition, makes clinical decisions, and manages their healthcare. E/M services are essential components of patient care and are used to determine the appropriate level of care and billing for a particular medical visit.
E/M services encompass many medical encounters, including office visits, hospital visits, consultations, and emergency room visits. These encounters involve interactions between healthcare providers and patients, during which the provider assesses the patient’s medical history, performs a physical examination, and engages in medical decision-making to diagnose, treat, and manage the patient’s condition.
Evaluation and Management (E/M) Service Changes in 2021
In 2021, the field of medical billing underwent several transformative shifts. Among these changes, a significant revision was made to the regulations governing office visits and the guidelines surrounding evaluation and management (E/M) procedures. E/M services, often characterized by frequency, carried notable compliance implications for medical practices.
The revised E/M guidelines in 2021 aimed to streamline the process of documenting patient visits. This overhaul also acknowledged the valuable time that physicians dedicate to supplementary tasks like coordinating patient care. Read more about these CMS E/M 2021 guidelines and billing codes summarized in a previous post.
Our clients often ask whether E/M services and medical procedures can be billed on the same day.
Billing for Evaluation and Management (E/M) services and procedures on the same day are common in medical practices. But it can sometimes raise red flags during audits, as payers may scrutinize the documentation and coding closely. If the E/M service is integral to the procedure and doesn’t meet the criteria for separate billing, then billing for both services might not be appropriate.
There are specific guidelines and rules that healthcare providers need to follow to ensure accurate and compliant billing. The guidelines can vary based on the payer (e.g., Medicare, private insurance) and the billed codes. Here’s a general overview of billing E/M services and medical procedures on the same day:
- Modifier Usage: One common way to indicate that an E/M service and a procedure were performed on the same day is by using appropriate modifiers.
- Modifier 25: The most used modifier in this context is Modifier 25. This modifier is added to the E/M code to indicate that the E/M service was a significant, separately identifiable service from the procedure. ( Read an example of using Modifier 25 as explained by the American College of Cardiology).
- Modifier 24: Utilize modifier 24 alongside the suitable level of E&M service in the following scenarios:
- If an unrelated E&M service is performed by the same physician, beginning from the day after the procedure, within the 10- or 90-day postoperative period.
- If the documentation verifies that the service’s exclusive purpose was to address a new or unrelated condition and not for postoperative care.
- If the same physician oversees immunosuppressant therapy during the postoperative period after a transplant.
- If the same physician administers unrelated critical care during the postoperative period.
- If the same diagnosis as the original procedure can be attributed to the new E&M service, provided the issue arises at a different anatomical site.
Do not use modifier 24 in the following cases:
- When the E&M service pertains to a surgical complication or infection (included in the surgical package).
- When the service involves the removal of sutures or other wound care (included in the surgical package).
- When a surgeon admits a patient to a skilled nursing facility due to a condition linked to the surgery.
- When the medical record indicates that the E&M service is connected to the surgery.
- When the service takes place outside the postoperative period for the procedure.
- When services are provided on the same day as the procedure, the treatment is related to diagnosis.
- When reporting, exams are carried out for routine postoperative care.
- Documentation of Medical Necessity: Comprehensive and accurate documentation is key. Each service should have its own documentation supporting the service level provided. The documentation should include details about the patient’s condition, the decision-making process, and the work performed.
- Codes and Levels: Select the appropriate E/M code based on the level of service provided and the associated documentation. Similarly, choose the correct code for the procedure performed.
- Payer Policies: Different payers might have their own rules and policies regarding billing E/M and procedures on the same day. It’s essential to familiarize yourself with these policies to ensure proper billing and reimbursement.
The rules and guidelines surrounding E/M billing can be complex and subject to change. It’s always advisable to consult with your medical billing and coding professionals or an outsourced medical billing team to ensure that you follow the billing guidelines for accurate claims submission.
Reduce the denials and get payments timely by implementing changes in modifiers and coding guidelines. Do you have queries or concerns regarding E/M visits billing along with procedures? Contact us today to book a free consultation session.
