How to Bill Evaluation and Management Codes

Q: I am in need for guidance on how to bill evaluation and management (E&M) codes in addition to acupuncture the same date of service, I have never been paid for an exam when done with acupuncture and I believe I am doing it wrong. In addition, assuming I should be paid for this examination, how often may I bill for this service? May I bill and E&M on every visit as I do perform an evaluation on every visit?

A: Your question is one that is common and generally misunderstood by the acupuncture profession, especially new practitioners or ones new to insurance billing and coding. Evaluation and management codes (E&M) are utilized to indicate a separate and distinct evaluation above and beyond the pre-, intra- and post- service evaluation associated with the acupuncture codes. To demonstrate this distinction, the billing protocol for the use of an E&M code with acupuncture is append the E&M code with modifier -25. This -25 modifier is to indicate that the E&M is distinct, separate, and above and beyond the acupuncture evaluation associated with the acupuncture services.

The coding on the claim would be in this manner, 99203-25 or 99213-25, new patient or established patient mid-level examination services, with acupuncture 97810 to 97814. This -25 alerts the insurance that the E&M is to be separately reimbursed. Without this modifier, the E&M service will automatically be denied. Note the use of the modifier does not reduce or alter the fee of the E&M or acupuncture services. The lack of the modifier is the most common coding and billing error made by acupuncturists and the reason many in the profession incorrectly assume they cannot be paid for an exam, they simply never billed it in its proper format. This should ameliorate your first inquiry for the reason you have never been paid for an E&M service with acupuncture. You simply lacked the coding with its proper modifier.

Here is the direct instruction from the CPT 2016 Professional Edition, pages 658-659. "Evaluation and management services may be reported in addition to acupuncture procedures when performed by a physician or other health care professionals... (E&M) may be reported separately using modifier -25 if the patient's condition requires a significant, separately identifiable E/M service above and beyond the usual preservice and post service work associated with the acupuncture services. The time of the E/M service is not included in the time of the acupuncture service."

It is, in fact, compulsory to perform an examination of your patient in order to determine their condition, determine that acupuncture is an appropriate mode of care, and determine a subsequent acupuncture treatment protocol. In fact, I would assume that it would be considered unprofessional conduct to not do an examination prior to the initiation of care. The key factor on the billing is to demonstrate the E&M as a separately reimbursable service by appending the code with modifier -25.

Now, to address your second question as to whether you may bill an E/M on each visit, the answer is a simple and direct, no. It is understood that there indeed is an evaluation on each visit but on these routine follow up visits the day-to-day evaluation is not considered above and beyond the evaluation associated with the acupuncture codes and services.

To understand this protocol, clearly it must be understood as to what is inclusive to the acupuncture codes and services. There is an inherent pre-, intra- and post- service evaluation associated with the acupuncture service. Preservice would include, but not be limited to, review of patient's record prior to face-to-face time, review of patient complaints, interim history and pertinent evaluation and assessment of the patient. Intraservice is the hands on treatment time which includes hand washing, choosing and cleaning the points, insertion, stimulation, removal and proper disposal. Postservice would include assessment of treatment effectiveness, communication with the patient and or family (including education, discussion and counseling), planning for the next treatment session, as well as documentation of the services while the patient is present.

Based on these protocols, it becomes apparent that the day to day evaluation is clearly part of the acupuncture service. As far as a re-examination per standard protocols, it is approximately 30 days to perform a full evaluation above and beyond the typical day-to-day assessment. There may be special circumstances that require evaluation/re-evaluation for acupuncture within the 30-day period (e.g., the patient presents with a new diagnosis or the patient's condition substantially changes). Additional coding of E&M services are considered for these special circumstances when the patient's condition requires a significant separately identifiable evaluation and management service above and beyond the usual preservice and postservice work associated with the acupuncture service. Circumstances that are typical might include:

• There is a definite, measurable, change in the patient's condition requiring a significant change in treatment plan.
• Patient fails to respond to treatment requiring a change in treatment plan.
• Patient's condition reaches maximum therapeutic benefit and is ready for discharge.
• Patient reports new and significant complaints requiring a level of history and exam above and beyond the associated with the acupuncture service.
• Patient has a new injury or exacerbation and re-injury.