Cardiology Coding Alert

Modifier -25 Alert:

OIG Cracks Down on Modifier -25, Will Your Office Be in Compliance?

Cardiologists who have slipped into the habit of routinely adding modifier -25 should beware: Auditing for overuse of this modifier will begin late this fall, according to the Office of the Inspector General (OIG).

In its plan of work, the OIG contends that physicians are deliberately billing this modifier in cases where it does not apply, for the sole purpose of increasing reimbursement.

The CPT explains that -25 is a modifier attached only to evaluation and management (E/M) codes that designate a Significant, Separately Identifiable E/M service by the Same Physician on the Same Day of the Procedure or other Service.

This modifier should be used to bill for a procedure or service that you normally couldnt get reimbursed for because it is considered part of another procedure or service, says Stephanie Gajic, CPC, director of clinical coding management and education at Cardiology of Georgia in Atlanta.

For example, suppose a patient comes in for his annual treadmill and the cardiologist discovers a new onset of mild carotid disease and addresses it. By appending modifier -25 to the office-visit code (99213), the physician can be reimbursed for both the stress test and an established office visit. Without the modifier, only the stress test code 93015 would be reimbursed, because it includes physician supervision, interpretation and report.

Many times modifier -25 is the appropriate code; the problem is that it has been used indiscriminately and inappropriately, Gajic says.

Dont Risk an Audit

Follow these tips to make sure your practice is in compliance.

1. Use modifier -25 for the unexpected and unrelated. Use this modifier if, on a day the cardiologist performed a procedure or service, the patients condition required a significant, separately identifiable E/M service.

For example, if, during the course of a patients annual treadmill, the physician discovers hypertension and addresses it, you would append modifier -25 to the office visit and code for the treadmill separately, explains Gajic.

You would use modifier -25 when the service or procedure performed was over and above, and unrelated to, the reason the patient came, she says.

2. Modifier -25 may also be used with diagnostic procedures. Take, for example, an established patient who presents in your cardiology office with chest pain. The cardiologist suspects unstable angina and, after having taken history and physical, wants to perform a cardiac catheterization to discover any physical abnormalities that may be causing the pain.

This E/M service appended with modifier -25 should be over and beyond the usual preoperative and postoperative care associated with the procedure that was performed, says Dianne Willard, MBA, RRA, CCS-P, practice manager, AHIMAs staff liaison for the Society of Clinical Coders.

Add modifier - 25 to the appropriate level of E/M service for established patients; in this case, 99212 - 99215. Also use a diagnosis code of 411.1 Intermediate coronary syndrome. You want to show payers that the cath was needed to find out what was causing the unstable angina, Willard explains.

3. Dont use -25 with an E/M code that has a minimum level of service. If the office visit is a 99211 -- evaluation and management of an established patient that may not require the presence of a physician -- you probably wouldnt be performing services that are above and beyond, notes Willard.

Gajic agrees. You need all three components of an E/M -- history, exam, and medical decision-making in order to append -25, she says.

In fact, Gajic recommends not appending modifier -25 for anything less than a level three service (99213). It just doesnt make sense to use it for a minimal level of care. If I were an auditor, thats the type of red flag Id be looking for, since by adding the modifier to a lower level of service you would be increasing your reimbursement, she says. (See adjacent column for chart of levels of E/M services.)

4. Dont mistake modifier -25 for -57, Decision for Surgery. While modifier -25 explicitly states that it is not used to report an E/M service that resulted in a decision to perform surgery , distinguishing it from the surgery-related modifier -57 can still be confusing.

For example, one might think of cardiac catheterization as an invasive procedure, i.e. surgery, that calls for modifier -57. Yet its not.

A cath is a diagnostic service done to provide the cardiologist more data, not to correct something, therefore, you would use a -25 modifier, not a -57, explains Willard.

But modifier -25 could be used on the same day as a minor surgical procedure such as angioplasty or a stent is performed, notes Gajic.

Whether you use a -25 or -57 depends on whether it is minor or major surgery, she says. (The CPT doesnt define major or minor surgery, but HCFA determines the category according to each procedures global period.)

Gajics rule of thumb is a simple one: Forget about using modifier -25 with major surgery, such as a pacemaker. For minor surgery -- if the E/M service falls within the global period -- use -25.

Just remember major surgery equals modifier - 57, she says.

5. Be careful with stress tests. For example, some Medicare carriers state that a patient coming in for an initial stress test must have a complete history and physical -- even if he or she is an established patient.

Yet to be able to bill for a cardiovascular stress test (93015), and an established office visit (99213 - 99215), the patient must be there for an additional problem other than the stress test, Gajic explains.

In order to add modifier -25 and bill for a separate identifiable service, the physician should be treating the patient for another diagnosis other than the one he or she is having the stress test for, she says. The [clinical office] note should be able to stand alone for the other diagnosis, with its own history, exam, and medical decision making.

Otherwise, you can not use modifier -25 or be reimbursed for an office visit because physician supervision, interpretation, and report is included in the CPT description for the stress test.

If a patient comes in for a yearly treadmill, has no complaints and the cardiologist does a problem-focused exam such as check heart and peripheral pulse, you shouldnt use modifier -25. Its not appropriate in that case, she says.
For example, Gajic relates the scenario of an 83-year-old man who comes in for his stress test six months after angioplasty and stent to the LAD. He complains that he can no longer run the distance he used to.

The cardiologist performs a stress test and finds the patient had no chest pain, no signs of ischemia, and normal first and second heart sounds. The notes indicate another physician is monitoring cholesterol.

This is a problem-focused exam, the patient is having no episodes, and another doctor is monitoring his other symptoms. Therefore, you can only bill for the stress test, she explains. In this case, you cant bill for an office visit by using modifier -25.

7. Make sure documentation backs up billing. While you dont have to automatically include documentation on every claim you send in with a modifier -25, you must make sure the reason for using the modifier is included in your office note, says Gajic. It is crucial that the documentation substantiates the use of the modifier, she points out.

Modifier -25 Utilization Chart

Only use modifier -25 with the following established office-visits codes for 97 E/M Guidelines

Level 3 E/M service - 99213, Office or other outpatient visit for established patient, requires at least two of the following:

1. An expanded problem focused history

2. an expanded problem focused examination

3. Low complexity medical decision-making.

Level 4 E/M service - 99214, Office of other outpatient visit for established patient, requires two of these three components:

1. A detailed history

2. A detailed examination

3. Moderate complexity medical decision-making

Level 5 E/M service - 99215, Office or other outpatient visit for the established patient, requires two of these three components:

1. A comprehensive history

2. A comprehensive examination

3. High complexity medical decision making.

-25 vs. -57: CPT 98 Differentiated

Modifier - 25. Significant, Separately Identifiable E/M Service by the Same Physician on the Same Day of the Procedure or other Service.

The physician may need to indicate that on the day a procedure or service identified by a CPT code was performed, the patients 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 that was performed. This circumstance may be reported adding the modifier -25 to the appropriate level of E/M codes, or the separate five digit modifier 09925 may be used. Note: This modifier is not used to report an E/M service that resulted in a decision to perform surgery. See modifier 57.

Modifier -57. An evaluation and management service that resulted in the initial decision to perform the surgery may be identified by adding the modifier -57 to the appropriate level of E/M service, or the separate five digit modifier may be used.