Examination for Professional Practice in Psychology (EPPP)

Correct: The documentation of identical or ‘cloned’ notes across different patients is a significant compliance risk. It suggests that the provider is using templates that do not accurately reflect the unique medical necessity or the specific clinical work performed for each individual patient. For interventional surgeons, follow-up care must be documented with patient-specific details regarding the wound healing, vascular status, and any complications to justify the level of E/M service billed.

Incorrect: Documenting time is a legitimate way to determine the E/M level under current guidelines, so a 25-minute duration for a 99214 is not a compliance failure. Reviewing external data and coordinating care are elements that support higher complexity in medical decision-making, thus supporting the code rather than indicating a risk. Performing a focused exam rather than a comprehensive one is often clinically appropriate for a follow-up and does not automatically invalidate a Level 4 code if the medical decision-making or time requirements are met.

Takeaway: Cloned documentation that lacks patient-specific clinical details is a primary indicator of non-compliance and a failure to demonstrate medical necessity in E/M coding.

Correct: According to CPT guidelines and CMS policy, an E/M service provided on the same day as a procedure is only billable if it is significant and separately identifiable. This means the provider must have performed work that exceeds the usual pre-procedural and post-procedural work inherent in the procedure itself. Documentation must clearly reflect this distinction to justify the use of Modifier 25 and prevent unbundling, which is a key focus for regulators looking for conflicts of interest or revenue-driven coding practices.

Incorrect: The suggestion that a chronic condition automatically justifies a separate E/M is incorrect because the specific encounter must involve distinct work; routine monitoring of a condition is often part of the procedural assessment. The idea that Modifier 25 alone or a brief summary validates the service is a common misconception; the documentation must meet the ‘significant and separately identifiable’ threshold. Finally, the physical presence of a supervising physician does not change the CPT bundling rules or global period requirements for PAs.

Takeaway: To bill a separate E/M service with an interventional procedure, documentation must prove the evaluation was significant and distinct from the standard work included in the procedure code.

Correct: According to CPT guidelines and regulatory compliance standards, Modifier 25 is used to report a significant, separately identifiable E/M service by the same physician on the same day as a procedure. For an interventional pathologist, if the evaluation involves a level of complexity or medical decision-making that goes beyond the standard ‘informed consent’ and ‘brief history’ typically bundled into a minor procedure, it is appropriate to code the E/M separately, provided the documentation supports the distinct nature of the service.

Incorrect: The claim that E/M is always bundled is incorrect because CPT allows for separate reporting when the service is significant and distinct. Consultation codes are often restricted by payers (such as Medicare) and have specific requirements that may not be met in a simple procedural referral. The requirement for an unrelated diagnosis is a common misconception; the E/M service can be related to the same symptom or condition as the procedure, as long as the evaluation itself is distinct and exceeds the routine work associated with the procedure.

Takeaway: To compliantly report an E/M service with an interventional procedure, the documentation must prove the evaluation was significant, separately identifiable, and exceeded the routine pre-procedural work.

Correct: Modifier 25 is used to report a significant, separately identifiable E/M service by the same physician on the same day of a procedure. In this scenario, the management of the patient’s chronic psoriasis and the full-body skin check constitute work that is distinct from the focused evaluation of the specific nevus being biopsied. To support the use of Modifier 25, the medical record must clearly show that the E/M service involved work exceeding the routine preoperative and postoperative care associated with the punch biopsy.

Incorrect: Modifier 57 is incorrect because it is specifically used for the decision for surgery related to major procedures with a 90-day global period, whereas a punch biopsy is a minor procedure. Reporting only the biopsy is incorrect because it fails to capture the significant medical decision-making involved in managing the psoriasis. Omitting the biopsy code to avoid NCCI edits is a form of inaccurate coding; both the procedure and the E/M should be reported if they are supported by documentation as distinct services.

Takeaway: For interventional dermatology, an E/M service performed on the same day as a minor procedure requires documentation of a significant, separately identifiable service to justify the use of Modifier 25.

Correct: Under the current E/M guidelines (2021/2023), the ‘Amount and/or Complexity of Data’ element of MDM is one of the three components used to determine the level of service. For high-complexity cases (Level 5), the auditor must find evidence of specific tasks such as the independent interpretation of a test performed by another physician, or the review of prior external records, or a discussion of management with an external physician. These actions directly contribute to the ‘Data’ element of MDM.

Incorrect: Total time (Option B) is an alternative method for leveling E/M services but does not specifically validate the MDM data element. HPI elements (Option C) are part of the 1995/1997 guidelines and are no longer the primary driver for determining the level of office/outpatient E/M services. The physical location of documentation (Option D), such as a flow sheet, is a matter of record-keeping preference and does not define the complexity or amount of data analyzed for MDM purposes.

Takeaway: Auditors must verify specific evidence of data analysis, such as independent test interpretation or inter-provider consultation, to support the ‘Data’ component of high-level Medical Decision Making.

Correct: According to CPT guidelines, Modifier 25 is used to indicate that on the day a procedure or service was performed, the patient’s condition required a significant, separately identifiable E/M service above and beyond the other service provided or beyond the usual preoperative and postoperative care associated with the procedure. The key is that the E/M work must be distinct from the routine evaluation that is already bundled into the surgical or procedural package.

Incorrect: Providing a secondary diagnosis code is often helpful but not a strict requirement for Modifier 25; the same diagnosis can be used if the E/M service is truly distinct. Performing the service in a different clinical setting is not a requirement for the modifier, as it can be performed in the same suite. Requiring specific physical exam elements unrelated to the site is a common misconception; the distinction is based on the overall medical decision-making and the nature of the evaluation rather than a specific count of exam elements.

Takeaway: To justify Modifier 25, documentation must prove the E/M service was significant and distinct from the routine pre-procedural assessment bundled into the procedure itself.

Correct: The primary risk in interventional pathology coding involves the misinterpretation of CPT guidelines regarding the reporting of immediate cytopathology evaluation (e.g., CPT 88172). According to coding standards, these services are reported per lesion, not per pass. If multiple passes are performed on a single lesion, only one unit is billable. Mitigation requires clear documentation of distinct anatomical sites to justify multiple units, ensuring compliance with payer regulations and preventing over-billing.

Incorrect: Requiring physiological monitoring data or respiratory rates does not address the core coding risk of unit misapplication. Mandating a dermatologist’s review for skeletal biopsies is clinically inappropriate and does not mitigate coding errors related to interventional pathology. Including a detailed endocrine history, while relevant to general health, is not a requirement for procedural coding of an FNA and fails to address the risk of unbundling or incorrect unit reporting.

Takeaway: Accurate coding for interventional pathology requires that immediate adequacy assessments be reported based on the number of distinct lesions sampled rather than the number of needle passes performed.

Correct: In the context of an internal audit, the first step after identifying a deficiency is to perform a root cause analysis. This involves a detailed comparison of the source documentation (the pathology report) with the regulatory coding standards (CPT and NCCI) to determine exactly why the coding does not match the clinical activity. This ensures that the corrective action is appropriately targeted and addresses the actual source of the error.