EM Coding Alert

You need to prove significant, separately identifiable service before employing the modifier.

Within the web of E/M issues that could make a practice a target for payer audits, another danger also lurks: modifier misuse. One of the most common reasons practices get nicked by auditors is the improper use of modifiers.

“It’s important for everyone to know when to use a modifier, and to use them right all the time,” warns Suzan (Berman) Hauptman, MPM, CPC, CEMC, CEDC, medical coding director at Acusis in  Pittsburgh, Pa. “Adding a modifier just because you know a service gets paid when it is appended is not correct.”

Sitting high atop the list of misused modifiers is 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).

For example, if a coder automatically reports 99212 (Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: a problem focused history; a problem focused examination; straightforward medical decision making) with modifier 25 appended when a patient is scheduled for a procedure, auditors will notice. Often, the modifier is not appropriate because of the intended visit or the documentation might be lacking the significantly separate component.

Remember: Do not report a procedure code and an E/M-25 unless you can prove in the documentation that a significant, separately identifiable E/M occurred in addition to the procedure.