ED Coding and Reimbursement Alert

Answer 3 questions to tell for sure

If you want to recoup reimbursement for your modifier -25 claims, make sure you can separately identify your ED physician'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).

1. Does your E/M service stand alone?

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

For Medicare, to properly code using 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 to the emergency department following a bicycle accident, and the ED physician does more than just walk into the room and perform a scalp laceration repair. And, the patient has an abrasion on the knee and complains of abdominal pain. The doctor documents an examination, which includes the knee, abdomen and a full neurological exam.

You want to include all the needed E/M documentation, including the plan to repair the laceration. Then you want separate documentation for the repair 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 ED physician 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.

2. Do you need to have additional diagnoses?

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 scalp laceration following a motor-vehicle accident and otherwise has no complaints, you might be left with only scalp laceration as a diagnosis code. However, even per Medicare's more restrictive rules, an E/M might apply if the ED physician performed a thorough neurological and multisystem exam.

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. However, the ideal situation is when the procedure code has a different diagnosis than the E/M code. This makes justifying the modifier that much better for carriers, she says. In all cases, if you have an additional diagnosis, you should always report it.

3. Have you considered modifier -57?

Modifier -57 (Decision for surgery) applies to E/M services also, but you should not use this routinely for procedures the ED physician performs with E/M visits. For Medicare, you should use modifier -57 only if the physician 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 global 0- to     10-day global period of a minor procedure.

For example, the ED physician evaluates a humerus fracture and performs the necessary treatment. In this case, you'd report 24500 (Closed treatment of humeral shaft fracture; without manipulation) to represent the procedure, and append modifier -57 to represent the physician's decision for surgery associated with this major procedure.

For a laceration repair (12011, Simple repair of superficial wounds of face, ears, eyelids, nose, lips, and/or mucus membranes; 2.5 cm or less), you could append modifier -25 to the E/M if the physician 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.