Ob-Gyn Coding Alert

Learn how you can report both an E/M and preventive service

Thinking you know everything about modifier 25 could throw your claim into payer limbo-land. Review these insider tips, and your claim will sail through every time.

1. Identify Claim Makeup to Solve -Which-

All the talk of when to use and not use modifier 25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) may have muddied the modifier's fundamentals. -Should I attach modifier 25 to the well-visit code or to the -sick- code?- asks Shoeb Amin, MD, FAAP, with Bloom, Amin and Banker in Haverstraw, N.Y.

There's a catch: Modifier 25 can be applicable on either a preventive medicine service code (99395-99397) or a problem-oriented office visit code (99201-99215, Office or other outpatient visit ...). The answer depends on your claim's makeup.

2. Put 25 on Problem E/M Following Well

Here's when you should append modifier 25 to the problem-oriented visit. Catherine Brink, CMM, CPC, president of Healthcare Resource Management Inc. in Spring Lake, N.J., says to put modifier 25 on 99201-99215 when the encounter meets these criteria:

1. the ob-gyn provides a sick visit at the same time as a preventive visit

2. the preventive visit was the reason for the scheduled visit.

Why: The ob-gyn provides the sick service -secondary to the preventive,- Brink says. Therefore, the 25 goes on the sick visit to indicate that the problem E/M is significant and separate from the preventive medicine service.

How it works: During the course of a preventive medicine service, a patient has a medical complaint, such as irregular periods or pelvic pain. -The physician then performs a separate E/M to address the medical problem,- Brink says.

3. Bill Problem Part When 3 Criteria Are Met

You should charge for the sick visit (in addition to the preventive medicine service) only under these conditions:

1. -The physician performs a separate E/M service, meaning all three key components of history, examination and medical decision-making for a new patient office visit (modifier 25 on 99201-99205) and two out of these three key components for an established patient office visit (modifier 25 on 99212-99215),- Brink says.

2.Performance and documentation for the problem-oriented portion (modifier 25 on 99201-99205 or 99212-99215) are separate from the preventive medicine service (99395-99397). -You cannot -double-dip- between the preventive medicine service and the sick visit,- Brink says. Each service must be separately performed and documented.

3. The encounter involves a separate and distinct problem as determined by the following guidelines:

A. The problem involves evaluation such as diagnostic testing or treatment with a prescription.

B. The problem would have required the patient to return for another visit if you had not addressed it at this encounter.

C. You have a separate and distinct ICD-9 diagnosis for the problem-oriented service.

4. Use 25 When Well Visit Results in Procedure

Make sure you always append modifier 25 on a preventive medicine service code (99395-99397) when the encounter also involves a procedure. Modifier 25 indicates that the well-woman visit is separately identifiable from the procedure, such as a pessary insertion (57160, Fitting and insertion of pessary or other intravaginal support device).

Keep in mind: In 2006, CMS released Transmittal 954, which instructs you to use modifier 25 only when your ob-gyn provides a significant and separately identifiable E/M service on the same day as a procedure that has a global period. (For the exact language, go to www.cms.hhs.gov/transmittals/downloads/R954CP.pdf  to read the full transmittal.)

But you may find that many payers -- including Medicare carriers -- routinely and inappropriately deny claims without modifier 25 appended to the E/M code, regardless of the same-day procedure's global period. Consequently, you should contact your payers to make sure you-re meeting their requirements, and you may need to use modifier 25 anyway.

5. Follow Payer Policy for E/M and Screening

Many plans also require you to append modifier 25 to 99395-99397 on claims involving a screening service. -In these instances, however, the modifier is not technically required by CPT.-

You may need to append modifier 25 to 99395-99397 on claims for a preventive medicine service and a screening (such as 77080, Dual-energy x-ray absorptiometry [DXA], bone density study, 1 or more sites; axial skeleton [e.g., hip, pelvis, spine]) provided the same day.