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Please note that information on this site was NOT authored by Dr. Frederic A Matsen III and has not been proofread or intended for general public use.  Information was intended for internal use only and is a compilation for random notes and resources.

If you are looking for medical information about the treatment of shoulders, please visit shoulderarthritis.blogspot.com for an index of the many blog entries by Dr. Frederick A Matsen III.

E&M Coding Info

Shoulder and Elbow take on E+M coding

Hx -

The New Patient Encounter Form covers for up to 205.

The Return Patient Encounter Form cover you up to 214.

 

PE -

1995 Guidelines -

Problem Focused - a limited examination of the affected body area or organ system.

You need one exam bullet

 

Expanded Problem Focused - a limited examination of the affected body area or organ system and other symptomatic or related organ system(s).

You need one exam bullet in at least 2 systems

 

Detailed - an extended examination of the affected body area(s) and other symptomatic or related organ system(s).

You need one exam bullet in at least 2 systems.  You must have 4 bullets in one system.  Left and right exams of the same type (ROM, strength, etc.) only count as one bullet.

• General appearance of patient (eg, development, nutrition, body habitus, deformities, attention to grooming)
• Inspection, percussion and/or palpation with notation of any misalignment, asymmetry, crepitation, defects, tenderness, masses or effusions
• ROM with notation of any pain (eg, straight leg raising), crepitation or contracture
• Stability with notation of any dislocation (luxation), subluxation or laxity
• Strength and tone

 

Comprehensive - a general multi-system examination or complete examination of a single organ system.

You need one bullet in at least 8 systems or a complete examination of single organ system.

• Constitutional - general appearance
• Cardiovascular - No edema
• Respiratory - No cyanosis
• Musculoskeletal - ROM
• Skin - No rashes or lesions
• Neurologic - SILT M/R/U
• Psychiatric - mental status
• Hematologic/lymphatic/immunologic - No bruising
  

1997 Guidelines -

Problem Focused - perform and document at least 1 “bullet” from any system or area

You need one exam bullet

Expanded Problem Focused -Perform and document at least 6 “bullets” from any systems/areas.  Left and right exams of the same type (ROM, strength, etc.) count as two bullets.

You need six exam bullets

 

Detailed -Perform and document at least 12 “bullets” from at least 2 systems/areas.  Left and right exams of the same type (ROM, strength, etc.) count as two bullets.

You need 12 exam bullets and hit 2 systems

Comprehensive -At least 18 “bullets” from at least 9 systems/areas.  You ARE REQUIRED to have a minimum of 2 bullets in each of 9 systems

You need 2 exam bullets in 9 systems

MDM -

New Est	201 211	202 212	203 213	204 214	205 215
Diag/Mgt	1/-	1	2	3	4
Data	1/-	1	2	3	4
Risk	min/-	min	low	mod	high

 

Breakdown - At least two criteria must be met or exceeded.

201/202/212

Patient has a problem

---

Read or order x-ray

---

Minor Problem

 

203/213

Old problem that is getting worse or not getting better

---

Order and read x-ray

---

Chronic problem or new sprain or PT/OT or MR arthrogram

 

204/214

New problem

---

Order and read x-ray

order MRI, CT, EMG, labs - or - review old records

---

Rx drug or Surgery or nonop/non manipulation tx of Fx or dislocation

 

205/215

New problem requiring x-ray

---

Order and read x-ray

2 of - order MRI, CT, EMG, labs - or - review old records

---

Surgery c risk factors or closed manipulation of Fx or dislocation

 

1997 Guideliness

New Patient 3 of 3 (Hx, PE and MDM) must agree

Established Patient (seen within 3 years) 2 of 3 must agree

For MDM 2 of 3 (Dx, Data and/or Risk) must agree

Time can be used if counseling and/or coordination of care dominates (more than 50%) of the physician/patient and/or family encounter

1997 E/M Documentation Requirements

Hx

Problem Focused (99201, 99212)
Expanded Problem Focused (99202, 99213)
Detailed (99203, 99214)
Comprehensive (99204/05, 99215)

CC (Chief Complaint)
HPI (History of Present Illness) “elements”
ROS (Review of Systems)
PFSH (Past,Family,Social History)

CC (Chief Complaint)
histories must begin with a CC

HPI Elements

• Location - place, whereabouts, site, position. Where on the body is the patient experiencing signs or symptoms? (e.g., pain in groin)

• Quality - A description, characteristics, or statement to identify the type of sign or symptom. (e.g., burning pain in groin).

• Severity - Degree, intensity, ability to endure. The patient may describe the severity of their signs or symptoms by using a self-assessment scale to measure subjective levels. (e.g., History of mild burning pain in groin that has become more intense)

• Duration - Length of time. How long has patient been experiencing the signs or symptoms? (e.g., History of intermittent mild burning pain in groin that has become more intense and frequent for the last two weeks)

• Timing - Regulation of occurrence. A description of when the patient experiences signs or symptoms (e.g., history of intermittent mild burning pain in groin that has become more intense and frequent for the last two weeks).

• Context - Circumstances, cause, precursor, outside factors. A description of where the patient is or what the patient does when the signs or symptoms are experienced (e.g., history of intermittent mild burning pain in groin that has become more intense and frequent for the last two weeks since the patient bent down to pick up son and continues to feel intense pain when bending).

• Modifying Factors - Elements that change, alter or have some effect on the complaint or symptoms (e.g., history of intermittent mild burning pain in groin that has become more intense and frequent for last two weeks since the patient bent down to pick up son; continues to feel intense pain when bending. (Patient currently on Motrin 800 mg BID for past 3 weeks without relief)

• Associated Signs and Symptoms - Factors or symptoms that accompany the main symptoms. What other factors does patient experience in addition to this discomfort/pain? (e.g., Shortness of breath, lightheadedness, nausea/ vomiting)

Brief HPI consists of 1-3 HPI elements

Extended HPI consists of at least 4 HPI elements or the status of at least 3 chronic or inactive conditions (REVIEW 3DX).

ROS
Medicare has designated 14 Body Areas or Systems in the Comprehensive Systems Review:

Mention of 1 or more items within a system counts as 1 system

If a full systems review is conducted, one can document positive findings, then state “all others negative in the 14 system review”. This will count for a full 14 system review

• A problem pertinent ROS inquires about the system directly related to the problem(s) identified in the HPI. The patient's positive responses and pertinent negatives for the system related to the problem should be documented.

• An extended ROS inquires about the system directly related to the problem(s) identified in the HPI and a limited number of additional systems. The patient's positive and pertinent negative responses for two to nine systems should be documented.

• A complete ROS inquires about the system directly related to the problem(s) identified in the HPI plus all additional body systems. At least ten organ systems must be reviewed. Those systems with positive or pertinent negative responses must be individually documented. For the remaining systems, a notation indicating all other systems are negative is permissible. In the absence of such a notation, at least ten systems must be individually documented.

Sample ROS (? 1997 E/M):

PFSH (Past/Family/Social History)

Where required, mention of 1 item in a category satisfies the requirement.
Pearl: Allergies/Meds counts as PH, smoking status counts as SH
Past History: the patient's past major illnesses, injuries, operations, treatments, hospitalizations, current medications, allergies, age appropriate immunization status, and age appropriate dietary status.

Family History: a review of medical events in the patient's family including health status or cause of death of parents, siblings, and children; specific diseases related to problem(s) identified in CC, HPI, or ROS; and / or diseases of family members which may be hereditary or place the patient at risk.

Social History: an age appropriate review of past and current activities (such as marriage or living arrangements; employment history; use or drugs, alcohol, and tobacco; education; sexual history; and other related relevant social factors).

PE

Problem Focused - perform and document at least 1 “bullet” from any system or area.
Expanded Problem Focused -Perform and document at least 6 “bullets” from any systems/areas.
Detailed -Perform and document at least 12 “bullets” from at least 2 systems/areas.
Comprehensive -At least 18 “bullets” from at least 9 systems/areas.  You ARE REQUIRED to have a minimum of 2 bullets in each of 9 systems.

 

 

General Multi-System Examination

Constitutional Measurement of any three of the following seven vital signs:  1) sitting or standing blood pressure, 2) supine blood pressure, 3) pulse rate and regularity, 4) respiration, 5) temperature, 6) height, 7) weight (May be recorded and measured by ancillary staff) General appearance of patient (eg, development, nutrition, body habitus, deformities, attention to grooming)     Eyes Inspection of conjunctivae and lids Examination of pupils and irises (eg, reaction to light and accommodation, size, and symmetry) Ophthalmoscopic examination of optic discs (eg, size, C/D ratio, appearance) and posterior segments (eg, vessel changes, exudates, hemorrhages)     Ears, Nose, Mouth and Throat External inspection of ears and nose (eg, overall appearance, scars, lesions, masses) Otoscopic examination of external auditory canals and tympanic membranes Assessment of hearing (eg, whispered voice, finger rub, tuning fork) Inspection of nasal mucosa, septum and turbinates Inspection of lips, teeth and gums Examination of oropharynx:  Oral mucosa, salivary glands, hard and soft palates, tongue, tonsils and posterior pharynx     Neck Examination of neck (eg, masses, overall appearance, symmetry, tracheal position, crepitus) Examination of thyroid (eg, enlargement, tenderness, mass)     Respiratory Assessment of respiratory effort (eg, intercostal retractions, use of accessory muscles, diaphragmatic movement) Percussion of chest (eg, dullness, flatness, hyperresonance) Palpation of chest (eg, tactile fremitus) Auscultation of lungs (eg, breath sounds, adventitious sounds, rubs)     Cardiovascular Palpation of heart (eg, location, size, thrills) Auscultation of heart with notation of abnormal sounds and  murmurs      Examination of: Carotid arteries (eg, pulse amplitude, bruits) Abdominal aorta (eg, size, bruits) Femoral arteries (eg, size, bruits) Pedal pulses (eg, pulse amplitude) Extremities for edema and/or varicosities     Chest (Breasts) Inspection of breasts (eg, symmetry, nipple discharge) Palpation of breasts and axillae (eg, masses or lumps, tenderness)     Gastrointestinal (Abdomen) Examination of abdomen with notation of presence of masses or tenderness Examination of liver and spleen Examination for presence or absence of hernia Examination (when indicated) of anus, perineum and rectum, including sphincter tone, presence of hemorrhoids, rectal masses Obtain stool samples for occult blood test when indicated

Genitourinary      MALE: Examination of the scrotal contents (eg, hydrocele, spermatocele, tenderness of cord, testicular mass) Examination of the penis Digital rectal examination of prostate gland (eg, size, symmetry, nodularity, tenderness)      FEMALE Pelvic examination (with or without specimen collection for smears and cultures, including Examination of external genitalia (eg, general appearance, hair distribution, lesions) and vagina (eg, general appearance, estrogen affect, discharge, lesions, pelvic support, cystocele, rectocele) Examination of the urethra (eg, masses, tenderness, scarring) Examination of bladder (eg, fullness, masses, tenderness) Cervix (eg, general appearance, lesions, discharge) Uterus (eg, size, contour, position, mobility, tenderness, consistency, descent or support) Adnexa/parametria (eg, masses, tenderness, organomegaly, nodularity)     Lymphatic      Palpation of lymph nodes in two or more areas: Neck Axillae Groin Other     Musculoskeletal Examination of gait and station Inspection and/or palpation of digits and nails (eg, clubbing, cyanosis, inflammatory conditions, petechiae, ischemia, infections, nodes) Examination of joints, bones and muscles of one or more of the following six areas:  1) head and neck; 2) spine, ribs and pelvis; 3) right upper extremity; 4) left upper extremity; 5) right lower extremity; 6) left lower extremity.  The examination of a given area includes: Inspection and/or palpation with notation of presence of any misalignment, asymmetry, crepitation, defects, tenderness, masses, effusions. Assessment of range of motion with notation of any pain, crepitation or contracture Assessment of stability with notation of any dislocation (luxation), subluxatoin or laxity. Assessment of muscle strength and tone (eg, flaccid, cog wheel, spastic) with notation of any atrophy or abnormal movements.     Skin Inspection of skin and subcutaneous tissue (eg, rashes, lesions, ulcers) Palpation of skin and subcutaneous tissue (eg, induration, subcutaneous nodules, tightening)     Neurologic Test cranial nerves with notation of any deficits Examination of deep tendon reflexes with notation of pathological reflexes (eg, Babinski) Examination of sensation (eg, touch, pin, vibration, proprioception)     Psychiatric Description of patient's judgement and insight      Brief assessment of mental status including: Orientation to time, place and person Recent and remote memory Mood and affect (eg, depression, anxiety

MDM

The elements of medical decision making

* Risk is not determined by points. Is assigned directly off the risk table

Diagnoses and Management Options

Quantifying diagnoses and management options

Totals: 1, minimal; 2, limited; 3, multiple; 4, extensive

Data - Based on the amount and complexity of data to be reviewed

Quantifying the amount and complexity of data to be reviewed

Totals: 0-1, minimal or none; 2, limited; 3, moderate; 4, extensive

Risk -The level of risk to the patient is based on
Problem Risk: the number /complexity / uncertainty of diagnoses and prognoses
Diagnostic Procedure Risk: the number and complexity of Diagnostic Procedures to be done
Management Risk: the number/types/complexity of medical interventions and therapeutic procedures utilized
*The highest single element on the entire “risk table” determines the level of risk

Quantifying the risk of complications, morbidity and mortality

Risk: ”High” (Dx/ Proc/ Mgt )
Any 1 of the following will qualify:

• chronic Pb with severe exacerbation

• Acute Pb life/limb threatening

• acute neuro/mental status change (TIA, CVA, Sz, weakness)

• CV contrast studies (with risk factors)

• endoscopy (with risk factors)

• major surgery (elective or emergent)

• IV narcotics, toxic drugs, requiring monitoring,parenteral treatments

• Closed treatment of Fx or dislocation with manipulation

• DNR decision necessitated by condition, not routine discussion
  

Risk: “Moderate”
Any 1 of the following will qualify:

• 1 chronic Pb with mild exacerbation

• 2 chronic stable Pb

• new Pb, uncertain prognosis

• acute illness with systemic Sx

• Physiologic test with stress, angiogram

• Dx endoscopy without risk factors

• deep needle/ incisional Bx ; -centesis

• Rx drug; IV meds; Closed Fx

• minor surgery with risk factors

• elective major surgery without risk factors

*If you prescribe any medication from Polytrim eye drops to Atenolol, risk becomes Moderate

Low Risk:

• 2 or more self limited/minor Pb

• 1 chronic stable Pb

• Acute uncomplicated illness/injury

• Test, non-stress

• Superficial biopsy

• OTC meds, PT

• IV fluids, minor surgery
  

Minimal Risk:

• 1 self limited minor Pb

• Lab/XR/EKG

• Rest/gargle

• Bandage/Dressings

Counseling, Time and/or Coordination of Care

In the case where counseling and/or coordination of care dominates (more than 50%) of the physician/patient and/or family encounter (face-to-face in the office or other outpatient setting or floor/unit time in the hospital or nursing facility), time is considered the key or controlling factor to qualify for a particular level of E/M services. This includes time spent with parties who have assumed responsibility for the care or decision making of the patient, whether or not they are family members (eg foster parents, legal guardians, locum parentis).

• If the physician elects to report the level of service based on counseling and/or coordination of care, the total length of time of the encounter (face-to-face or floor/unit time, as appropriate) should be documented and the record should describe the counseling and/or activities performed to coordinate care.

 

Counseling is defined as one or more of the following areas:

• Diagnostic results, impressions, and/or recommended diagnostic studies

• Prognosis

• Risks and benefits of management (treatment) options

• Instructions for management (treatment) and/or follow-up

• Importance of compliance with chosen management (treatment) options

• Risk factor reduction

• Patient and family education.

 

Time is the explicit factor in selecting the following level of E/M service codes:

• hospital discharge day management

• critical care services

• prolonged physician services

• physician standby service

• care plan oversight services

• preventive medicine counseling

 

The inclusion of time in certain E/M service codes (e.g., new and established patient, office or other outpatient services) are averages, and therefore represent a range of times which may be higher or lower depending on actual clinical circumstances.

Modifiers that family physicians are likely to use most.

Modifier -25, "Significant, Separately Identifiable Evaluation and Management Service by the Same Physician on the Same Day of the Procedure or Other Service," may be the most important for family doctors. The classic use of this modifier is for an annual preventive-medicine encounter during which the patient says, "Oh, by the way, ..." As a result, you address the "by the way" ailment and perform the preventive service. In this case, you may submit codes for both a preventive service (such as 99396) and a regular office visit (such as 99213) by attaching -25 to the office-visit code. This tells the third-party payer that you did perform two significant, separately identifiable E/M services for the same patient on the same date, and it should keep the payer from bundling the services.

 

Use modifier -21, "Prolonged Evaluation and Management Services," when an E/M service takes more time than is usually required for the highest level of service within a given E/M category. For example, you see an established patient with multiple, concurrent problems, spending more than 90 minutes in assessment and counseling with the patient and family. You feel the examination and medical decision making easily qualify the service as a 99215. But in this case, because the service was prolonged (according to CPT, the typical time for a 99215 is 40 minutes) "or otherwise greater than that usually required for the highest level" code in its category, you could append -21 to the 99215 and get credit for the extra time.

 

Modifier -59, "Distinct Procedural Service," is similar to modifier -25, but it's applicable to procedural, rather than E/M, services. Attach -59 to a code to indicate that a procedural service is distinct or independent from other services performed the same day, particularly when the services or procedures aren't normally reported together but are appropriate under the circumstances.

 

For example, you incise and drain two abscesses -- one simple and one complicated -- for one patient. If you bill for these services using the appropriate CPT codes (10060 and 10061), it may appear as though you're coding twice for the same service. However, by appending -59 to one of the codes, you clarify that the services were distinct and that both should be reimbursed.

 

Here are several other situations in which modifiers can help you get paid appropriately for what you do:

• You provide the professional component of a service for which someone else has provided the technical component (for example, you interpret an X-ray someone else has taken). You can identify your part in this service (unless there's a separate CPT code for the professional component) with modifier -26, "Professional Component."

• You provide postoperative management for a patient following surgery by another physician. You can attach modifier -55, "Postoperative Management Only," to the procedure code to identify your part in the service.

• You want to bill for laboratory services that you purchased from an outside lab. Use modifier -90, "Reference (Outside) Laboratory," with the appropriate laboratory-service code. Medicare requires labs to bill for such services directly, but not all insurers follow that policy.

Categories of Evaluation & Management Services

Brief List of categories and code ranges for E/M services:

Office or Other Outpatient Services

New Patient 99201 - 99205

Established Patient 99211 - 99215

Hospital Observation Services 99217 - 99220

Hospital Inpatient Services

Initial Hospital Care 99221 - 99223

Subsequent Hospital Care 99231 - 99233

Observation or Inpatient Care Services

(including admission and discharge services) 99234 - 99236

Hospital Discharge Service 99238 - 99239

Consultations

Office Consultations 99241 - 99245

Initial Inpatient Consultations 99251 - 99255

Follow-up Inpatient Consultations 99261 - 99263

Confirmatory Consultations 99271 - 99275

Emergency Department Services 99281 - 99288

Pediatric Patient Transport 99298 - 99290

Longer List:

A. Office or Other Outpatient Services (99201-99215)

• New Patient is defined as a patient who has not been seen by the physician, or any member of the group practice who is of the same specialty, within the past three years.

• Established Patient is defined as a patient who has seen the physician, or any member of the group practice who is of the same specialty, within the past three years.

• A physician who is covering or on call for another physician should not classify the patient's encounter as a new patient unless the patient's attending physician (or any member of the group who is of the same specialty) has not seen the patient within the past three years.

• Time must be indicated in the medical record when the time factor is used to select a code from this category. Do not consider the time spent by other staff (e.g., nurse, NP or PA) as part of the face-to-face time.

 

B. Consultations (99241-99275)

• Definition: A consultation is a type of service provided by a physician whose opinion or advice regarding the diagnostic and/or treatment options is requested by another physician or other appropriate source. The consulting physician may initiate treatment.

• Office or Other Outpatient Consultations: Follow-up visits initiated by the consultant should be reported using the appropriate established patient office visit code. If the attending physician requests an additional opinion regarding the same or a new problem, the office consultation codes may be used again.

• Initial Inpatient Consultations: A consulting physician should report only one initial consultation code per hospital or nursing facility admission.

• Follow-up Inpatient Consultations: A re-evaluation of a patient in order to finalize an opinion or advice.

• Confirmatory Consultations: A second or third opinion is requested to justify medical necessity or appropriateness of treatment. A confirmatory consultation can take place in any setting.

 

C. Preventive Medicine Services

 

D. Hospital E/M Services

1. Hospital Observation Status (99217-99220)(99234-99236)

• These codes are used to report services provided to a patient designated as under "observation status" in a hospital.

• Initial Observation Care (codes 99218-99220): Use the codes from this category to report services for the first (or additional) day(s) of a multiple-day observation stay. The two higher level codes require a comprehensive history and physical examination. The lowest level code requires a detailed or comprehensive history and physical examination.

• Observation Discharge Care (code 99217): Report this service only for the final day of a multiple-day stay.

• Observation or Inpatient Care Services (codes 99234-99236):use codes to report observation or inpatient services where the patient is admitted and discharged on the same date of service. The two higher level codes require a comprehensive history and physical examination. The lowest level code requires a detailed or comprehensive history and physical examination.

• Typical time has not been yet been established for these services.

 

2. Hospital Inpatient Services (99221-99239)

• Initial Hospital Care: The codes in this category are for reporting services provided only by the admitting physician. Other physicians providing initial inpatient E/M services should use consultation or subsequent hospital care codes, as appropriate.

• Subsequent Hospital Care: The codes in this category are for reporting inpatient E/M services provided after the first inpatient encounter (for the admitting physician) or for services (other than consultative) provided by a physician other than the admitting physician.

• A hospitalized patient may require more than one visit per day by the same physician. Group the visits together and report the level of service based on the total encounters for the day. Third-party payers vary on their requirements for reporting this service.

• Hospital Discharge Services: Use these codes for reporting services provided on the final day of a multiple-day stay.

• Time is the controlling factor for assigning the appropriate hospital discharge services code. Total duration of time spent by the physician (even if the time
  spent is not continuous) should be documented and reported. These codes include: final examination, discussion of hospital stay, instructions to caregivers, preparation of discharge records, prescriptions and referral forms.

 

3. Critical Care Services (99291-99292)

• Critical Care Services can be provided in any setting.

• The physician must provide constant attendance or constant attention to a critically ill or injured patient. The physician need not be constantly at bedside per se but is engaged in physician work directly related to the individual patient's care.

• Time is the controlling factor for assigning the appropriate critical care code. Total duration of time spent by the physician (even if the time spent is not continuous) should be documented and reported.

• Services in critical care units must meet the guidelines to be billed as critical care.

• The following procedures are considered integral to the performance of critical care, and should not be reported separately:

  • cardiac output evaluation (93561-93562)

  • chest x-ray interpretation (71010-71020)

  • gastric intubation (91105)

  • temporary transcutaneous pacing (92953)

  • ventilation management (94656, 94657, 94660 and 94662)

  • vascular access (36000, 36410, and 36600)

• CPT 2000 Changes: The critical care narrative description is redefined and removes "unstable" as a qualifier to assign critical care codes but focuses on medical care for a critically ill or injured patient. Critical illness/injury is defined as an acute impairment of one or more vital organ systems that could jeopardize the patient's survival. Critical care services include treatment or prevention of further deterioration of the patient's medical condition even if the patient is "stable". The descriptor stating care "requiring the constant attendance of the physician" changed to state the physician "must devote his/her full attention to the patient, and therefore cannot provide services to any other patient during the same period of time".

 

4. Emergency Department Services (99281-99285)

• Services are provided in an organized hospital-based facility for the provision of unscheduled visits for patients who present for immediate medical attention. The facility must be available 24 hours per day.

• Critical care services should be reported using the appropriate critical care codes.

• CPT 2000 Changes: Code 99285 descriptor revised to clarify the patient's clinical condition and/or mental status may preclude obtaining past pertinent medical history or other events.

 

5. Neonatal Intensive Care Services ( 99295-99298)

 

E. E/M Modifiers

Before assigning a final code, it is important to check for potential modifiers that should be assigned to report an altered service or procedure (e.g., an unusual or special circumstance that affects the service or procedure). The following is a review of the modifiers used most often with the codes in the evaluation and management section.

1. Prolonged Evaluation and Management Services

• Modifier - 21 or 09921

• Used only with the highest level of each E/M category when the service provided is greater than that usually designated for that code.

• Documentation should be provided to describe the circumstances.

• This modifier does not affect reimbursement under Medicare's physician fee schedule.

 

2. Unrelated Evaluation and Management Service by the Same Physician During a Postoperative Period

• Modifier - 24 or 09924

• This modifier is used to differentiate between a related and unrelated service during the post-operative period. (Documentation must be submitted to the carrier when this modifier is assigned.) The ICD-9-CM code must substantiate that the care was provided for a condition unrelated to the condition that required surgery.

 

3. Significant, Separately Identifiable Evaluation and Management Service by the Same Physician on the Same Day of a Procedure or Other Service

• Modifier - 25 or 09925

• This modifier is used to differentiate services associated with global payment from those to be considered separately for payment. (Sending supporting documentation with the claim is not required when this modifier is applied.) This modifier should not be used to indicate that the visit or consultation resulted in the decision to perform major surgery.

 

4. Mandated Services

• Modifier - 32 or 09932

• Used to inform the third-party payer that the service is required or mandated (e.g., PRO, governmental, legislative or regulatory requirement, or third party payer).

 

5. Reduced Services

• Modifier - 52 or 09952

• In some instances, a service or procedure may be partially reduced or eliminated at the physician's discretion.

 

6. Decision for Surgery

• Modifier - 57 or 09957

• Identifies an evaluation and management service provided by the physician on the day before, or the day of a surgery during which the initial decision to perform surgery was made

Updated 7 Dec 2003