Gastroenterology Coding Alert

Documentation must prove significant, separate E/M for reimbursement Did you know that when your gastroenterologist performs an EGD with biopsy and performs a separate evaluation and management (E/M) service on the same patient on the same date, the E/M service is often reportable using modifier -25?

But be warned: if you don't use the modifier correctly, you could open your office to a long appeals process, a denial - or even an audit. Read on for some practical coding information regarding modifier -25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service). Modifier -25 Use Is in Feds' Crosshairs Improper use of modifier -25 has been on the rise in the past decade, and it's made regulators take notice. In 2003, the Department of Health and Human Services instructed its Office of the Inspector General (OIG) to start paying extra attention to modifier -25 claims in an attempt to catch people who were taking advantage of the modifier.

However, experts contend that if you do things right the first time on your modifier -25 claim, you'll have no reason to sweat the OIG and will reduce the chances of denial, regardless of carrier. Proving Separate Service Is Priority 1

The most difficult modifier -25 issue is ensuring that the E/M service is actually separate from the other procedure, not just a component of the procedure, according to Lisa Center, CPC, of Freeman Health System in Joplin. Mo.

"Each service - the E/M and the procedure - needs to be able to stand alone [on the claim]. That is the point of the -25 modifier; to show it is a separately identifiable service," Center says. E/M for PDT Nausea = Reportable Service Take a look at this scenario, in which you can report both a procedure code and an E/M code with the help of modifier -25:

A patient now undergoing photodynamic therapy (PDT) for treatment of thoracic cancer reports to the office for an upper gastrointestinal endoscopy (EGD) with biopsy. When checking in at the front desk, the patient also reveals that he has had severe nausea attacks and vomiting since the PDT began a month ago. The gastroenterologist performs the EGD with biopsy, and then provides level-two E/M service for the nausea attacks.

Since the time and expertise the doctor expended on the patient's nausea were totally separate from the biopsy, you can report the E/M service and the procedure. On your claim, you should:

report 43239 (Upper gastrointestinal endoscopy including esophagus, stomach, and either the duodenum and/or jejunum as appropriate; with biopsy, single or multiple) for the biopsy.

attach ICD-9 code 150.1 (Malignant neoplasm of esophagus; thoracic esophagus) to 43239.

report 99212 (Office or [...]