Cahaba GBA performed data analysis of claims billed with Pulmonary Diagnostic Procedures (CPT 94010 – 94799) and Evaluation and Management services (CPT 99211-99213). According to the data analysis, overpayments are associated with evaluation and management services (99211-99213) billed without modifier 25 on the same date of service as a pulmonary diagnostic procedure. If a physician in attendance for a pulmonary function study obtains a history and performs a physical related to the pulmonary function testing, separate reporting of an evaluation and management service is not appropriate. If a significant, separately identifiable E&M service is performed unrelated to the performance of the pulmonary function test, an E&M service may be reported with modifier 25. Cahaba’s data revealed that there is no provider specific issue but a widespread issue based on data from Jan-May 2013 dates of service. There was $337,814 paid for E&M codes billed without modifier 25 during this time period.
Cahaba GBA requests providers review their billing of these codes and make any necessary corrections.