Internal Medicine Coding Alert

Published on Fri Mar 03, 2006 PDF

Here's how to determine whether your documentation will withstand OIG scrutiny

Get ready: Carriers are on the prowl for noncompliant modifier 25 claims--which puts your internist's deserved reimbursement at more risk than ever before. Follow this advice to ensure the documentation supports the physician's services and prevents paybacks.

In a recent study, the Office of Inspector General cast a spotlight on your 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), and the results weren't pretty. The OIG found a 35 percent error rate for modifier 25, resulting in $538 million in improper payments.

Result: The OIG is encouraging CMS' Part B carriers and Recovery Audit Contractors to scrutinize your claims that use this modifier, and you can expect to see a lot more pre- and postpayment audits for both modifiers.

In addition, CMS plans to revise Chapter 12, section 30.6.6 (B) of the Medical Claims Process Manual to clarify that physicians must maintain appropriate documentation to support modifier 25 claims, even though Medicare doesn't require that you send this documentation along with the claim, according to the agency's administrator, Mark B. McClellan, MD, PhD, who wrote a letter to the OIG addressing the improper payments.

To protect your claims, use these strategies.

How Documentation Can Protect Modifier 25 Charges

Although many IM practices struggle with modifier 25 documentation, the modifier's descriptor of a significant, separately identifiable E/M service doesn't cause most of the problems.

Only 2 percent of improperly coded modifier 25 claims involved E/M services that weren't significant and separately identifiable, according to the OIG.

Reality: Twenty-seven percent of modifier 25 claims had documentation of the procedure, but not the separate E/M.

For example: Documentation showed that the provider gave the patient a flu shot (90655-90658, Influenza virus vaccine ... with 90465-90474, Immunization administration ...) but offered no information about a separate E/M service (such as 99201-99215, Office or other outpatient visit for the evaluation and management of a new or established patient, or 99381-99397, Preventive medicine service) even when the physician rendered and billed for one. 
 
The OIG wants CMS to educate providers and reinforce the requirement that you should only use modifier 25 with services that are "significant, separately identifiable" and "above and beyond the usual preoperative and postoperative care associated with the procedure."

Best bet: When using modifier 25, you should remember this maxim:

"If you don't have a history, exam and medical decision-making [HEM], you can't bill an E/M," says Laureen Jandroep, OTR, CPC, CCS-P, CPC-H, CCS, director and senior instructor for CRN Institute in Absecon, N.J.

All procedures include some service related to patient evaluation and management, but a separate E/M should include its own HEM, in addition to being a purely significant and separately identifiable service, Jandroep says. 

Scratch Modifier 25 From Single-Code Claims

The news that all procedures contain a minor related E/M service may surprise you, but you probably know that modifier 25 submissions require a minimum of two codes. But that lesson escaped coders in 9 percent of the OIG's reviewed cases.

Modifier 25 was contained in 2.6 million claims even though the E/M visit was the only service the physician reported that day--meaning the modifier  was unnecessary.

"Without an accompanying initial service or procedure, you can't have a significant, separately identifiable service," says Kent J. Moore, a coding consultant in Leawood, Kan.

When you submit claims that consist solely of an E/M code, make sure you don't attach modifier 25 to the code, he says.

Note: To read the OIG's modifier report, visit http://oig.hhs.gov/w-new.html and download "Use of Modifier 25."