Oncology & Hematology Coding Alert

Hint: -000- and no global aren't the same thing If you-re confused by CMS- 2006 clarification of using modifier 25 during the global period, join the club. Our coding experts set the record straight on when you should -- and shouldn-t -- use this modifier.

Problem: To recoup more reimbursement, many practices report an E/M code with modifier 25 (Significant, separately identifiable E/M service by the same physician on the same day of the procedure or other service) for patients who visit for any checkup or procedure, regardless of whether their situation really justifies modifier 25, says John F. Bishop, PA-C, CPC, president and CEO of Bishop & Associates Inc. in Tampa, Fla. As a result, there has been a major crackdown on this modifier by the OIG and private payers.

Solution: Before you code another claim, get yourself out of automatic modifier 25 mode if you-re in it. Then, take a fresh look at the claim and the reason the patient visited the office. Was she there for a checkup under a global? Was she there for a procedure? Was she there for a checkup or procedure and then asked the doctor to look at something completely different? Unless you can answer -yes- to the third question, you should think twice before adding modifier 25 to your claim.

Don't Trip Over Transmittal Language In 2006, CMS released Transmittal 954, which covers -payment for evaluation and management services provided during global period of surgery.- (For the exact language, go to www.cms.hhs.gov/transmittals/downloads/R954CP.pdf to read the full transmittal.)  Good news: The transmittal clarifies that you do not need a separate diagnosis for modifier 25 and that payers need not look for documentation of medical necessity unless they suspect a pattern of abuse, says Barbara J. Cobuzzi, MBA, CPC, CPC-H, CPC-P, CHCC, president of CRN Healthcare Solutions, a coding and reimbursement consulting firm in Tinton Falls, N.J. But you still need to have the documentation of medical necessity in your chart.

You may have also noticed the transmittal's instructions to use modifier 25 when your physician provides a significant and separately identifiable E/M service on the same day as a procedure with a global period.

Tricky: Some coders mistakenly take this statement to mean that they can't use modifier 25 on a separate E/M service on the same day as a procedure with a zero global. A zero global and an XXX global (no global) are not the same, Cobuzzi says. Minor procedures with zero global days have a built-in prework component with a history and physical -- that is, a minor E/M, a history, exam and medical decision-making, she says.

So if the situation calls for modifier 25, be sure to append it to the E/M accompanying a zero-global [...]