Dermatology Coding Alert

Published on Thu Jul 01, 2004 PDF

Answer 3 questions to make sure

If you want to recoup reimbursement for your modifier -25 claims, make sure you can separately identify your dermatologist's E/M services from other procedures he performs for the same patient on the same day.

Here are three easy questions to ask yourself -- with answers from the experts -- to help guide you on the road to hassle-free 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).

CMS specifies that all procedures have an inherent evaluation and management component. Private payers also assume that there's some inherent E/M visit built into the reimbursement for procedure codes, because most dermatologists do a certain amount of "visiting" with the patient before any procedure.

This is why you need to be careful of overuse of modifier -25. Don't append modifier -25 just because your dermatologist spoke with the patient before doing the procedure, says Brenda W. Messick, CPC, a coding specialist in Atlanta.

For proper Medicare coding with modifier -25, the E/M service needs to be separate and identifiable from the minor procedure, and you need separate documentation for both services.

For example: A patient presents at your dermatology practice for a routine checkup. The dermatologist does more than just walk into the room and perform a checkup. The patient has a lesion on her arm that the dermatologist decides to excise.

You should include all the needed E/M documentation, including the plan to excise the lesion. Then you want separate documentation for the excision to show that you have reason to report a complete E/M separately. The repair documentation procedural note can be on the same sheet, or it can be on a separate piece of paper. You can provide the mini-operative report of the repair that tells how the dermatologist prepared the patient, what type of anesthetic he used, how many sutures he applied, and other relevant details.

Tip: When asking yourself if a procedure stands alone, separate the E/M notes from the procedure documentation in your medical record. If a reviewer could look at your medical notes and clearly see that the physician completed two separate and independently identifiable services, you can append modifier -25 for Medicare minor procedures.

For CPT payers, reporting works a little differently. CPT only bundles the E/M service performed subsequent to the decision for surgery. So, an E/M may be appropriate if the documentation supports a thorough history and physical exam prior to the decision for surgery, coding experts say.

You may think that in order for an E/M service to be separately identifiable, the service must have a separate diagnosis. Not true.

CPT states that an E/M service may be prompted by a symptom or condition that requires a procedure, but the procedure must be separate from any procedure your physician performed for the initial symptoms or conditions. You don't necessarily have to have another diagnosis.

For example, if a patient presents with a minor wart and otherwise has no complaints, you might be left with only wart removal as a diagnosis code. However, even according to Medicare's more restrictive rules, an E/M might apply if the dermatologist performed a more complicated exam from concerns based on the patient's previous history.

Warning: Never append modifier -25 to the procedure code, only to the E/M code. You may encounter situations, such as the one described above, in which the same diagnosis will be the reason for both the E/M visit and the procedure, says Tina Landskroener, CCS-P, of Total Healthcare Compliance in Las Vegas.

Modifier -57 (Decision for surgery) applies to E/M services also, but you should not use this routinely for procedures the dermatologist performs with E/M visits.

For Medicare, you should use modifier -57 only if the dermatologist decides that the patient needs a surgical procedure the day before or the day of the procedure, and the procedure has a global period of 90 days. Modifier -57 is allowed by Medicare to represent the work required to reach the decision for surgery for a major procedure. Modifier -25, on the other hand, is used to represent a separately identifiable E/M service that was performed during the 0- to 10-day global period of a minor procedure.

For example, the dermatologist evaluates a malignant lesion on the patient's back that measures 1.2 cm and performs the necessary excision. In this case, you'd report 11602 (Excision, malignant lesion including margins, trunk, arms, or legs; excised diameter 1.1 to 2.0 cm) to represent the procedure, and append modifier -57 to represent the physician's decision for surgery associated with this major procedure, such as a complex repair (13100, Repair, complex, trunk; 1.1 cm to 2.5 cm).

For a laceration repair (12011, Simple repair of superficial wounds of face, ears, eyelids, nose, lips, and/or mucous membranes; 2.5 cm or less), you could append modifier -25 to the E/M if the dermatologist performed a separately identifiable service in addition to the procedure.

Reimbursement tip: Every carrier is different, and not all of them follow the coding standards for using modifier -25. "Sometimes it's best to contact those carriers that keep denying you and find out how they want it billed. If a carrier ever tells you anything that is directly against an accepted CPT/ICD-9/HCPCS coding standard, then ask for it in writing," says Jamie Darling, CPC, of Graybill Medical Group in Escondido, Calif.