Dermatology evaluation and management (E/M) service code utilization
As part of its advocacy and educational efforts with the upcoming 2021 E/M coding changes, the AAD encourages dermatology practices to take a moment to understand their E/M code utilization.
The AAD coding team has reviewed Medicare’s 2019 national E/M code utilization data (PDF download) (previously known as "BESS Data") for claims submitted by all specialties. The data includes information on how dermatology compares to other specialties nationally in Medicare E/M service codes utilization.
This information can be used as a benchmark to compare your individual practice utilization of E/M service codes to the national Medicare utilization data. This comparison will assist you in determining whether your E/M coding practices make you an outlier when compared to the Medicare national utilization pattern of other dermatologists nationwide.
Note: The information provided does not reflect an individual practice’s utilization pattern of E/M service codes (bell curve) either statewide or among peers in your county or city. To determine your practice’s state, county, or city coding utilization pattern, coding data can be requested from the individual payers you are contracted with and analyzed for comparison to the Medicare utilization data listed below.
Medicare paid $590,334,997 in CY 2018 for dermatologic E/M claims compared to $630,706,066 in CY 2019. This represents a 6.8% increase in dermatology Medicare expenditures for these service from 2018 to 2019.
Dermatology payments compared to all specialties
According to the data, dermatology received a total of $96,673,074 for all new patient E/M codes representing 2.58% of the national Medicare expenditure for all specialties. The data shows that for all established patient E/M codes, dermatology received a total of $534,032,992 representing 0.45% of the national Medicare expenditure for all specialties.
Reporting an E/M service with a procedure?
Some private payers have not reimbursed for E/M services when reported either
on the same day as a minor procedure; or
previously paid E/M service within 60 days of another encounter with the same or similar diagnosis.
The American Medical Association’s Current Procedural Terminology (AMA CPT)TM coding guidance indicates that a significant and separately identifiable E/M service can appropriately be reported by appending modifier 25 to the E/M service code when reported on the same date as a minor procedure. The guidance further indicates that a different diagnosis code is not required for the E/M to be reported. Likewise, modifier 57 is appended to an E/M service code to indicate the encounter resulted in the initial decision to perform the surgery with a 90-day global period.
When it is appropriate to report a significant and separately identifiable E/M service, dermatologists are encouraged to exercise due diligence with medical record documentation to ensure the record supports a separate E/M service that is above and beyond that which is included in the procedure performed. The Academy continues to advocate to payers for the proper usage of modifier 25 and to appropriately reimburse dermatologists rather than go through costly claim denial appeals.
Minor procedures
Minor procedures are those procedures that carry a 0 or 10-day global surgical period. Excision (114xx, 116xx) and destruction (17xxx) codes are examples of minor procedures.
These procedures typically include a low (minimal) E/M service component which can hinder the reporting of a separate E/M service code on the same date as the procedure.
The 2019 National Correct Coding Initiative (NCCI) manual states: “The decision to perform a minor surgical procedure is included in the payment for the minor surgical procedure and should not be reported separately as an E&M service. …If a minor surgical procedure is performed on a new patient, the same rules for reporting E&M services apply. The fact that the patient is ‘new’ to the provider is not sufficient alone to justify reporting an E&M service on the same date of service as a minor surgical procedure.”
The following are best practices to consider when reporting an E/M service on the same date as the minor procedure:
The documentation for both the E/M and the surgery must be succinct in describing the services provided.
Once all the documentation related to the minor procedure, e.g. history of the lesion, examination of the site, and decision to perform the surgery, is accounted for, the remaining documentation must support the E/M level of service reported.
It is also good practice to check with your individual private payers for specific modifier 25 billing rules as they may be different from CMS guidelines.
Frequently asked questions
Q1. What does “significant and separately identifiable” mean when determining whether to report an E/M service with a dermatological procedure?
A1. “Significant and separately identifiable” is defined or substantiated by documentation that satisfies the relevant criteria for the respective E/M service reported on the same day as the procedure.
Q2. A Medicare beneficiary is sent by their primary care provider to the Mohs surgeon for consultation with a biopsy confirmed basal cell carcinoma (BCC) on the nose. The Mohs surgeon evaluates the new patient with a medically appropriate history and physical examination, determines Mohs surgery as the treatment plan, and proceeds with the surgery on the same day. The defect is repaired with a complex linear closure. Is it appropriate to report 9920X/25 with 17311, 1315x?
A2. According to November 2006 AMA CPT Assistant: Evaluation and Management (E/M) services provided on the same date of service as Mohs micrographic surgery may be reported if a significant separately identifiable service is performed and documented. A separately identifiable service may include an initial evaluation of a new patient, an initial consultation, or other E/M service, or it may include the decision to perform surgery.
Q3. A patient presents with a skin lesion on the forehead that requires a tangential skin biopsy. The physician notices a minor discoloration of the skin on the nose and advises the patient to avoid sun exposure and performs the biopsy. Does this support reporting an E/M code and the biopsy?
A3. No, according to comments from a CMS Contractor Medical Director, “by-the-way items brought to the provider’s attention by the patient are not a significant component of the E/M service and should not be considered.”
