ED Coding and Reimbursement Alert

Tip: Use this as an opportunity to review your modifier 25 processes.

Emergency departments are accustomed to reporting modifier 25 every day, since most ED physicians have to evaluate a patient thoroughly before performing any procedures. Fortunately, EDs escaped a near-miss recently, thanks to one insurer's last-minute decision not to slash pay for E/M codes appended with modifier 25.

Background: Last year, Anthem announced plans to cut pay for E/M codes appended with 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)  by 50 percent. As 2017 came to a close, Anthem decided it would go easier on practices by only cutting modifier 25 pay by 25 percent.

Fortunately, however, Anthem has scrapped the entire plan to reduce modifier 25 pay. Anthem's Chief Clinical Officer Craig E. Samitt, MD, MBA alerted the AMA in February that it would not be instituting any pay cuts for claims involving modifier 25.

EDs were relieved to have escaped the pay cuts, which are already in effect for Independence Blue Cross Blue Shield. However, Anthem's announcement doesn't give you carte blanche to report modifier 25 every time you perform an E/M and a procedure, because auditors are carefully scrutinizing these claims. For example, Part B recovery audit contractor Performant Recovery announced in January that it will be homing in on claims that violated CMS guidelines for these services. The RAC identified these as two separate audit issues, as follows:

• E/M codes billed with procedure codes that have 10-day global periods. "Procedures with Medicare Physician Fee Schedule global days of 10 include only E/M services on the day of the procedure and up to 10 post-operative days," Performant says on its website. "Physicians can indicate that E/M services rendered during the global period are unrelated to the surgical procedure by submitting modifiers 24, 25, and 57 on the E/M service."
• E/M codes billed with procedure codes that have 90-day global periods. "Procedures with MPFS global days of 90 include only E/M services on the day before the procedure, the day of the procedure and up to 90 days post-operative days," Performant says. "Physicians can indicate that E/M services rendered during the global period are unrelated to the surgical procedure by submitting modifiers 24 (Unrelated evaluation and management service by the same physician or other qualified health care professional during a postoperative period), 25, and 57 (Decision for surgery) on the E/M service."

Although EDs won't use modifiers 24 or 57 frequently, modifier 57 can be used on procedures like fracture care and other services that have 90-day global periods. But no matter which modifier you're using, there is only one way to prove medical necessity for the separate E/M and procedure, and that is to have clear documentation. Typically, you won't submit documentation on your modifier 25 claims, but if the payer denies the claim you'll have to provide documentation on appeal.

A separate diagnosis is not required per CPT^® to prove significantly separate services, and you won't always have different ICD-10 codes for the procedure and the E/M-25. No matter how you do it, medical record documentation is key to substantiating that an E/M was medically necessary in addition to the work involved in a procedure for the same patient during the same visit. Make sure to get your notes right before submitting an E/M-25, so you'll be ready if the payer requires you to appeal the claim.