Orthopedic Coding Alert

Remember, global days dictate which modifier is correct.

When it comes to modifiers 25 and 57, too many coders miss coding opportunities; or, worse, code a separate evaluation and management (E/M) service using the modifiers when it isn’t allowed.

This isn’t intentional. Two of the most commonly misunderstood, and therefore incorrectly used, modifiers are 25 (Significant, separately identifiable evaluation and management service by the same physician or other qualified health care professional on the same day of the procedure or other service) and 57 (Decision for surgery). Even when an encounter calls for you to code a separate E/M modifiers 25/57, the documentation may not be complete enough to back it up.

That’s why we’ve talked to experts and prepared this two-part series on modifiers 25/57 and what it means for a service to be “significant and separately identifiable.”

Rules Apply to 25 and 57

Remember that the rules for reporting modifiers 25/57 are the same, so you should follow the same set of advice when you’re considering either for your claim. The decision on which modifier to use comes down to the global period of the procedure the provider performs.

When the procedure performed after the E/M has a minor global period — 0 or 10 days — you’ll append modifier 25 to the E/M service code. When the procedure performed after the E/M has a major global period — 90 days — you’ll append modifier 57 to the E/M service code.

Other than that distinction, the rules for modifiers 25/57 can be used interchangeably.

Rely on the Documentation to Confirm a New Dx Earns an E/M

There are a few basic same-day situations to look for that may justify the use of modifier 25 on an E/M code, according to Jeffrey Lehrman, DPM, FASPS, MAPWCA, CPC, CPMA, principal, Lehrman Consulting LLC, Fort Collins, Colorado, during his HEALTHCON presentation, “What Exactly Is a Significant and Separately Identifiable E/M?”

• One problem gets E/M, and another problem gets a procedure
• New patient (most of the time, but not always)
• Established patient with a new problem
• Established patient with a change in an existing problem

However, whether to report the E/M and the procedure depends on what was performed and documented. “Often, providers actually are performing significant and separately identifiable evaluation and management, but they’re just not documenting it,” Lehrman said.

Example: A patient presents for a carpal tunnel (CT) injection. The patient has a recurring appointment for this procedure, and on this visit, the patient says, “My left knee hurts.”

The CT shot is the procedure; there’s no E/M there. But now there’s a new development in the form of a knee issue, something significant and separate from the procedure.

“Now, we ask questions and document how long they’ve been experiencing the problem, what makes it better and what makes it worse, what treatments are available, what has the patient tried already, has the patient experienced this before,” Lehrman said. Then the orthopedist diagnoses knee pain and recommends rest and over the counter (OTC) pain medication for treatment. Without a paragraph in the notes describing the evaluation and the management of the new problem, there’s no documentation that an E/M service occurred along with the CT shot. On paper, it looks like the procedure was the only billable service provided.

Remember H&P Does Not Equal E/M

In any encounter, history and physical examination (H&P) is just evaluation. “What’s missing from the H&P when comparing it to any E/M is the ‘M’ part, the management,” Lehrman said. “Management is the provider using their education and expertise and training to somehow manage that problem. That is work,” he continues.

What defines a significant and separately identifiable E/M service is the existence of an E/M service and a procedural service that don’t overlap in the work needed to complete either one, according to Chapter 1 of the National Correct Coding Initiative [NCCI] Policy Manual for Medicare services. “We can have work devoted to the E/M where there is no overlap with the work needed to perform the procedure, but the documentation must support that. That’s a key area where we see providers getting into trouble,” Lehrman said.

Example: A new patient comes in on referral to receive a steroid injection of a joint. The provider wants to submit a new patient E/M with the procedure. The lengthy note outlines the chief complaint, as well as a full history and exam, but the treatment section just outlines the procedure. The patient is new, and extensive notes were taken, but neither of those things warrants an E/M code on their own. This is especially true now that each of the office/outpatient E/M service requires a certain level of medical decision making in addition to a medically appropriate history and/or examination (unless coded on the basis of time).

“Attention was directed, the needle was stuck in, the product was injected. That’s all procedure. The work of the management portion of the E/M is missing. That note could be eight pages long, but the third-party payer is looking for the work associated with the E/M,” explained Lehrman.

New Patient Doesn’t Automatically Mean E/M

A new patient encounter with a procedure usually warrants the submission of an E/M, but nothing is automatic without documentation to back it up.

In fact, “Medicare global surgery rules generally prevent the reporting of a separate E/M service for the work associated with the decision to perform a minor surgical procedure regardless of whether the patient is a new or established patient … The fact that the patient is ‘new’ to the provider/supplier is not sufficient alone to justify reporting an E/M service on the same date of service as a minor surgical procedure,” according to the NCCI manual. Though NCCI is technically a Medicare program, many third-party payers consider Medicare rules to be a reasonable standard. “I suggest this as a good rule to normally apply to all,” said Lehrman.

These rules hold true for nonsurgical establishments and encounters, as well as preventive services. Just because the procedure isn’t surgical, doesn’t mean anything changes.