Cardiology Coding Alert

Ask yourself 4 questions to help support your choice.

A lot of coders have a love/hate relationship with modifier 25.

Why? Using this modifier allows you to get payment for an E/M service and a procedure on the same date. But not being certain about when the modifier is appropriate can lead to worry about whether your choice will lead to consequences like denials, paybacks, and audits. Check out this advice aimed at helping you get modifier 25 claims right the first time.

Remember: 25 Is for E/M Only

In basic terms, you use modifier 25 (Significant, separately identifiable evaluation and management service by the same physician or other qualified health care professional on the same day of the procedure or other service) only on an E/M service that is "separate and significant from another procedure or service at the same encounter," explains Melanie Witt, RN, MA, an independent coding expert based out of Guadalupita, N.M. This does not mean that the E/M requires a different diagnosis than the service, but the note must clearly indicate that the E/M dealt with issues that were not part of the other services even though it may have been for the same condition. The visit must be separately identifiable from the procedure, such that it is clear that the two services were medically necessary at the time the provider rendered both.

Example: The cardiologist sees an inpatient for acute claudication/ischemia of the foot and recommends peripheral vascular angiography with possible intervention. The same day, the cardiologist performs angiography and mechanical thrombectomy of the patient's popliteal artery.

In this case, you should include the following codes and modifiers on your claim:

• An E/M code, such as 99233 (Subsequent hospital care, per day, for the evaluation and management of a patient ...)
• Modifier 25 attached to the E/M code to show that the service was significant and separate from the procedures performed the same day
• A diagnostic angiography code, such as 75716 (Angiography, extremity, bilateral, radiological supervision and interpretation)
• Modifier 26 (Professional component) appended to the angiography code (75716) to indicate that you're coding only the angiography's professional component; this is the only service the cardiologist performed that has separate professional and technical components
• Popliteal artery thrombectomy code 37184 (Primary percutaneous transluminal mechanical thrombectomy, noncoronary, non-intracranial, arterial or arterial bypass graft, including fluoroscopic guidance and intraprocedural pharmacological thrombolytic injection[s]; initial vessel)
• A catheter placement code, such as 36247 (Selective catheter placement, arterial system; initial third order or more selective abdominal, pelvic, or lower extremity artery branch, within a vascular family).

Check Off These Elements on E/M-25 Claims

On modifier 25 claims, "the physician must show, by documentation in the medical record, that on the day he performed the procedure, the patient's condition required a separately identifiable E/M service above and beyond the usual care associated with the procedure that was performed," says Mary I. Falbo, MBA, CPC, CEO of Millennium Healthcare in Lansdale, Pa.

So you'll have to be sure that there is evidence of a separate E/M on your encounter forms before using modifier 25.

The key is recognizing when your provider's extra work is "significant" and, therefore, additionally codeable, says Falbo. CPT^® does not define "significant," unfortunately, but Falbo recommends asking yourself the following questions when deciding whether to report an E/M-25 along with another service:

1. Did the provider perform and document the key components of a problem-oriented E/M service for the complaint or problem?
2. Could the complaint or problem stand alone as a codeable service?
3. Is there a different diagnosis for this portion of the visit?
4. If the diagnosis will be the same, did you perform extra physician work that went above and beyond the typical pre- or postoperative work associated with the procedure code?

If you can answer "yes" to any of these questions, you might be able to report an E/M with modifier 25. However, if the visit was only to assess a patient prior to a procedure, the visit is unlikely to be separately identifiable, and thus would not be codeable.