Modifier -25: Optimize Reimbursement for E/M Service and Catheter Insertions on the Same Day

Proper use of modifier -25 (significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) and careful documentation of all services rendered can improve the chances for reimbursement of an evaluation and management (E/M) service (99201-99499) performed on the same day as a catheter insertion (36489, placement of central venous catheter, percutaneous, over age 2 years). But determining what both Medicare and third- party payers consider a separate and identifiable service is a challenge.

Simply adding the modifier to a CPT code is not enough, cautions Susan Callaway-Stradley, CPC, CCS-P, an independent coding consultant based in North Augusta, S.C. As with all surgical-type procedures, Medicare figures that a physician would usually just have to ask a few basic questions and do a cursory examination, which already would be figured into the cost of the procedure.

If the service rendered can meet the test, What did I do differently for this patient that I dont do for every patient receiving this treatment? says Callaway-Stradley, and the answer is a significant level of service, then you could append modifier -25.

The clearest rationale for separate coding with modifier -25 involves evaluations that uncover a systemic or chronic problem related to a catheters insertion, temporary replacement or removal, explains Jan Johnson, executive vice president, The Profile Group, a consultancy on hospital and physician reimbursement and compliance issues in St. Paul, Minn. These problems might include a diabetic complication, allergic reaction, fever, or a collateral venous access (459.89) related to the catheter insertion, or its temporary replacement or removal.

Medicare also expects a doctor to do a full evaluation and counseling with a new patient (99201-99205), explains Johnson. If as a result of the different levels of evaluation a catheter insertion is deemed reasonable and necessary, you can link an E/M with the catheter insertion using the modifier -25.

However, a problem can arise with an established patient visit when the patient has been previously seen and evaluated by a physician, she says. Many insurers feel its a slam-dunk that the catheter will be inserted. Why does the physician need to perform another E/M service? The rationale for a physician to do an E/M at inserting time would have to be very clear.

Coding for Counseling Time

Counseling concerning the catheters administration, workings, and complications to look out for, if not done previously, could meet the qualification of the modifier -25, and thereby be appended to an E/M code in the 99212-99215 (established patient, office or other outpatient visit).

According to Sharon Tucker, CPC, president, Seminars Plus, a consulting firm in Fountain Valley, Calif., if a patient presents with a serious infectious disease, such as [...]

- Published on 2000-03-01