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    When can modifier –25 be used with an E/M code?

     

    In a seminar that you taught recently, you said that writing a prescription, providing a sample of a prescription drug, or deciding to refill a prescription should be billed as a level 4 E/M code. Now, my E/M curve has almost all level 4s; is this going to trigger an audit?

    There are several issues that we will address in this question. First, we would like to apologize for a misunderstanding that your question represents. When we teach E/M coding guidelines, we attempt to carefully communicate accurate E/M coding according to the current published guidelines. Although “prescription drug management” referenced in your question above relating to prescription drugs dispensed (writing a prescription, giving a sample of a prescription drug, or renewing a prescription) to treat presenting problems represents a level 4 in terms of the risk element of medical decision-making, it cannot be considered as the sole determining factor in code level selection.

    When we teach E/M coding, you may recall that we talk about proper documentation for history, physical examination, and medical decision-making. We also talk about counseling and time where appropriate. Every part of E/M coding counts and is dependent upon both circumstance (place of service, patient status, etc.) and medical necessity. Space does not allow us to address all of these issues in this article.

    Read: How to get reimbursed for BPH water vapor ablation

    For this question, we will address scoring of medical decision-making (MDM). It sounds like you are focused on billing based on E/M key components and must have proper documentation for the other components of history and/or physical examination. For MDM, remember that the level of this component is based on two of three elements. The three elements are number of diagnoses or problems, amount of data, and amount of risk. Two of these three must meet or exceed the level selected for the MDM level of the visit.

    As an example, a patient who presents with prostate cancer that is being treated at this point with LHRH and monitoring of PSA for the visit would have a level 3 number of diagnosis or problem (one problem with active management), a level 2 amount of data (PSA review), and a level 4 risk (prescription drug management) with decision to administer and dosing for the LHRH. Based on MDM considered in total, the overall level of the MDM for the visit is level 3, even though the amount of risk based on prescription drug management would qualify for a level 4.

    Remember to document well and take a look at the visit as a whole. We would also recommend an updated education session through a respected organization such as Physician Reimbursement Services or the AUA.

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    Send coding and reimbursement questions to Ray Painter, MD, and Mark Painter c/o Urology Times, at [email protected] Questions of general interest will be chosen for publication. The information in this column is designed to be authoritative, and every effort has been made to ensure its accuracy at the time it was written. However, readers are encouraged to check with their individual carrier or private payers for updates and to confirm that this information conforms to their specific rules.


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    Ray Painter, MD
    Urologist Ray Painter, MD, is president of Physician Reimbursement Systems, Inc., in Denver, and is also publisher of Urology Coding and ...
    Mark Painter
    Mark Painter is CEO of PRS Urology SC in Denver.

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