How to Get Paid More for Patient Visits

Gail Garfinkel Weiss, MSW


January 30, 2013


Most physicians often go the extra mile for patients -- perhaps even if they don't get paid for those added efforts. However, sometimes you can reap financial as well as professional satisfaction for giving patients additional attention.

The key is to use the right evaluation and management (E&M) codes and modifiers -- and to be very careful about not overusing them, which could get you into trouble.

A key modifier that can raise your compensation when appended to an E&M code (not a procedure code) is modifier -25. As described in Appendix A of the Current Procedural Terminology (CPT) manual, modifier -25 is used to show that you performed a significant, separately identifiable E&M service above and beyond the service for which the patient was scheduled to see you. Or, you did E&M work "above and beyond the usual preoperative or postoperative care associated with the procedure that was performed." The additional complaint, condition, or symptom might, or might not, be related to the situation that prompted the visit.

David Zetter of Zetter Healthcare Management Consultants in Mechanicsburg, Pennsylvania, gives 4 examples:

  1. A patient comes in for a follow-up visit for his stable hypertension and osteoarthritis. He complains of a troublesome skin lesion that you remove at that same encounter. The lesion removal and the hypertension and osteoarthritis are unrelated. Therefore, the 2 services are separately billable.

  2. Your patient presents with a head laceration and is experiencing dizziness. You examine the patient for neurologic damage before repairing the laceration. Using modifier -25, it is appropriate to bill both the E&M service and the laceration repair code because your work exceeded what is typically associated with a routine preoperative assessment of a laceration. Separate diagnoses are not necessary.

  3. A patient is seen and evaluated for hypertension and knee pain. You give the patient a therapeutic injection in the knee. Because the procedure was not planned before the examination, the E&M service is separately reportable with modifier -25.

  4. When an established patient is seen in follow-up for diabetes mellitus, you perform an E&M service related to diabetes. During the visit, you also advise the patient to stop smoking and provide pointers on how to do so. Tobacco cessation counseling is a separately billable service when more than 3 minutes is spent talking about how to break a cigarette habit.

What You Need To Do

As noted, CPT guidelines do not require different diagnoses for an additional procedure or service to be reported separately via modifier -25. "The same diagnosis may accurately describe the nature or reason for the encounter and the separately billable procedure," Zetter says.

Still, supporting documentation is key, and it should indicate that the E&M service was indeed important, medically indicated, and above and beyond the care that usually accompanies the other service provided on that day. "Although not required, best practice would be to use 2 E&M notes to highlight the separate nature of the services," says Zetter.

Nancy Enos, a practice management consultant with the MGMA Health Care Consulting Group and owner of Nancy Enos Medical Coding in Warwick, Rhode Island, recommends that you first write a complete SOAP (subjective, objective, assessment, plan) note, and then a separate procedure note to indicate that it was medically necessary for the patient to undergo the second procedure during the same visit in which another procedure was scheduled. "Highlight the required documentation elements for the E&M level billed, and include enough documentation to support the separate service," says Enos.

When it comes to this modifier, David Zetter advises physicians to take the lead. He says, "Providers should indicate when modifiers should be used on a claim, instead of leaving it up to billing or data entry staffers who do not have clinical backgrounds and have not been fully trained in coding."

Once the guidelines are in place, however, be sure to bring your staff up to speed. "Each note should be evaluated to verify documentation for each service before billing an E&M on the same day as a procedure. There should never be a 'standing order' to add an E&M with modifier -25 under any circumstances," says Enos.