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Explore This IssueOctober 2011
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This patient encounter should be coded as 99214-25, 20600, 20610, and 76942.
Diagnoses: 714.0, 715.96, 535.00, E943.8
Modifier -25 is used to indicate that the patient required a significant, separately identifiable evaluation and management (E/M) service on the same day that she received a minor procedure. E/M services that result in the decision to perform a procedure on the same day are considered to be part of the evaluation for the procedure and are not separately billable. However, this patient had a separate problem (gastritis) which required E/M services and therefore the portion of the encounter related to the diagnosis and treatment of the patient’s gastritis are separately billable with the use of modifier -25. The E/M services related to the patient’s gastric symptoms included:
- Expanded problem-focused history;
- Detailed examination; and
- Moderate complexity decision making—treatment side effect (gastritis) requiring change in medication therapy and additional prescription medication to treat gastritis.
Even though ultrasound guidance was performed on each knee, this code is only allowed to be billed once. Centers for Medicare and Medicaid Services (CMS) states, “An MUE for a HCPCS/CPT code is the maximum units of service that a provider would report under most circumstances for a single beneficiary on a single date of service.” The MUEs were put into place by CMS on January 1, 2007 and are used to reduce the error rate for claims paid under Medicare Part B. For more information on the MUEs, visit the CMS website at www.cms.gov/Medicaid NCCICoding/06_NCCIandMUEEdits.asp. Please see this month’s Coding and Billing article, “MUEs and Muscular Ultrasound Guidance: An Unlikely Story,” above, for more information.