EM Coding Alert

Global days key to modifier 24/25 decision.

Because they look so similar, modifier 24 (Unrelated evaluation and management service by the same physician or other qualified health care professional during a postoperative period) and 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) are subject to some common coding myths.

But knowing the difference between the two could mean saving valuable work hours and gaining even more valuable revenue. That’s why we asked our experts to take a look at two of the most prevalent fictions regarding these frequently used modifiers and provide some much-needed factual clarity.

Myth: You Can Append Modifier 24 if E/M Service Related to Original Surgery

Truth: You should only attach modifier 24 to an appropriate E/M code when the physician renders the E/M service during a 10- or 90-day postoperative global period for reasons unrelated to the patient’s original surgery. Also, modifier 24 only applies to services your physician performs after the surgical procedure within the global period of that procedure.

Don’t forget: The medical record must support that the E/M visit was unrelated to the postoperative care, and the diagnosis should clearly indicate the reason for the unrelated postoperative encounter.

Coding scenario: The physician completed a L5 laminectomy on a patient. Two months later, the patient presented to the ED with headache, neck stiffness, and fever. The physician that performed the laminectomy was brought in and completed a lumbar puncture while the patient was still in the ED.

Assuming the problem is unrelated to the patient’s initial surgery, you will report the ER visit and lumbar puncture, appending the correct modifiers. The correct codes are as follows:

• 99282 (Emergency department visit for the evaluation and management of a patient, which requires these 3 key components: an expanded problem focused history; an expanded problem focused examination; and medical decision making of low complexity ...).Modifier alert: You should append modifier 24 to 99282 because the service was for a new problem during the laminectomy’s global period.
• 62270 (Spinal puncture, lumbar, diagnostic).Modifier alert: You should append modifier 79 (Unrelated procedure or service by the same physician or other qualified health care professional during the postoperative period) to 62270 to indicate the lumbar puncture was unrelated to the original laminectomy.

Myth: Modifier 25 Applies to Major Procedures

Truth: You should only append modifier 25 to indicate a distinct E/M with a minor procedure (zero or 10-day global period) performed on the same day.

When you append modifier 25, follow the following rules:

• You may use modifier 25 only when your provider’s documentation proves that he performed a medically necessary and “significant, separately identifiable” E/M service in addition to the original procedure. Your physician must include a separate History, Examination, and Medical-decision making (HEM) for the E/M service in his documentation.
• The E/M service must occur on the same calendar day as the original procedure, for the same patient.
• The procedure following the E/M would be a minor procedure, meaning that it has a zero or 10-day global period. For 90-day procedures, you would instead use modifier 57 (Decision for surgery) on the E/M service.

Coding scenario:  An established patient has a concussion, and the physician performs an E/M service to evaluate the concussion that includes a problem-focused history, a problem-focused exam, and straightforward medical decision-making. At the same session, the physician also administers a computerized neuropsychological test to determine the impact of the concussion.

For the neuropsychological test, you would report 96120 (Neuropsychological testing (eg, Wisconsin Card Sorting Test), administered by a computer, with qualified health care professional interpretation and report). Since the physician performed the neuropsychiatric testing and the E/M service in the same session, you should append modifier 25 to 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: aproblem focused history; a problem focused examination; straightforward medical decision making…).

Coding tip: You must make sure the documentation demonstrates the separate nature of the two services.

“In order to report both the E/M service and the procedure, the decision to perform the testing must be based on the findings obtained through the E/M service itself,” says Gregory Przybylski, MD, past chairman of neurosurgery and neurology at the New Jersey Neuroscience Institute, JFK Medical Center in Edison, New Jersey. “The E/M service would not be reportable if the purpose of the visit was to perform the test alone.”