Ob-Gyn Coding Alert

A common problem in ob/gyn practices has been getting paid for all services provided to a patient during a visit. The CPT provides a means for reporting significant, separately identifiable evaluation and management services by the same physician on the same day of the procedure or other service, by appending the additional services with the modifier -25. Most coders and carriers have been under the assumption that significant, separately identifiable meant you needed to have two distinct diagnosis codes, says Cynthia Thompson, CPC, of Gates, Moore & Company, a medical consulting firm in Atlanta, GA. But the 1999 CPT has clarified that this is not so.

The new language added to the modifier -25 description in Appendix A states: the E/M service may be prompted by the symptom or condition for which the procedure and/or service was provided. As such, different diagnoses are not required for reporting of the E/M service on the same date. In theory, using the same diagnosis code has been permitted with modifier -25 because (as OCA reported in April 1998) there are times when only one diagnosis code is present. According to Thompson, this is significant, because this is the first time it [non-requirement for two diagnoses] has been in writing as part of the CPT and lends support to the coder in defending the use of modifier -25.

One Diagnosis: Two Significant Separate Services

Suppose the patient comes in with postmenopausal bleeding, and after taking a history and performing an exam, the physician determines that an endometrial biopsy is warranted. The physician tells the patient he will be able to perform this procedure now and she agrees and signs informed consent. The biopsy is performed and the patient is released to go home with instructions. The physician documents the E/M service and the procedure separately on the chart, but the diagnosis for both is the samepostmenopausal bleeding, pending biopsy results (627.1). A modifier -25 is added to the E/M service to indicate that it was significant and separately identifiable from the endometrial biopsy also performed at this visit.

Getting Reimbursed

Of course, simply having CPT clarification does not automatically mean that payers will reimburse for separate services when submitted under the same diagnosis codes. In the past, the E/M service with the modifier -25 was automatically kicked out if it had the same diagnosis codes [as a procedure performed on the same day], Thompson says. We hope the carrier software will catch up with this, but I dont know if many have addressed changes. If the claim, or part of the claim, is denied, Thompson recommends calling the carrier and informing them of the change to the usage of modifier -25, and then asking if and when they will update their software. With the new clarification providing ammunition for defending claims, Thompson says its worth a try. You should be paid for all the services you provide without being forced to scramble for another diagnosis code.

Thompson reminds us that, as always, all claims, and especially those using modifier -25, need to be supported by good documentation. This will clearly demonstrate if significant, separately identifiable services were provided.