Otolaryngology Coding Alert

'Yes' to four basic questions means a separate E/M is billable.

Modidifer 25 concerns an E/M service performed with a minor procedure performed on the same patient during the same encounter. This may be the general rule on such situation, but may not apply at all times. First and foremost, you must prove that the E/M is a separate service, not inherent to the procedure. This is because minor procedures include a minor E/M service in their value. In order to be paid for an E/M in addition to the minor procedure, you must demonstrate to the payer that the E/M was "significant and separately identifiable."

But the guidelines do not end there. Following these pieces of advice will put you on the safe side of telling when and when not to use modifier 25.

1. Present Proof of Separate E/M

Since all minor procedure codes have an intrinsic E/M component in them, the physician must go above and beyond the usual preoperative and postoperative encounter with the procedure to justify a separate E/M -- and subsequently, the 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) to inform the payer that  they did do more than the minor E/M associated with the minor procedure. Coders should use modifier 25 when a significant, separately identifiable E/M service is performed by the same physician at the same face-to-face encounter as a procedure or other service, says Catherine Brink, CMM, CPC, president of Healthcare Resource Management of Spring Lake, N.J.

Modifier 25 claims can only be successful if you could establish its most vital element: a concrete proof that the procedure and E/M were truly separate, she adds.

Example: A 44-year-old established patient with a headache and nasal congestion visits the Otolaryngologist complaining of these  problems. The ENT performs and documents a history, exam and medical decision making. During the exam, the ENT documents that she cannot adequately visualize the nasal and sinus areas, and has decided to perform a diagnostic nasal endoscope. As a result of the history, exam and MDM, the physician concludes that the patient has a chronic sinus infection in the maxillary and frontal sinuses and prescribes nasal steroids and an antibiotic. You have here a complete E/M note describing the evaluation of the patient for his complaints of a recurring headache and nasal congestion. The note shows medical necessity for performing the nasal scope in addition to the exam in the E/M. The patient's chart and complaints support a significantly, separate and identifiable E/M. The E/M is associated to the complaint of a headache and the endoscope (31231, Nasal endoscopy, diagnostic, unilateral or bilateral [separate procedure]) to the chronic sinusitis and nasal congestion.

To help you determine if the E/M in the example is significant and separately identifiable, you could ask yourself the following questions:

• Did we perform and document the key components of a problem-oriented E/M service for the complaint or problem?
• Could the complaint or problem stand alone as a billable service?
• Is there a different diagnosis for this portion of the visit?
• If the diagnosis will be the same, did we perform extra physician work that went above and beyond the typical preor postoperative work associated with the procedure code?

Using these questions as guide, you should recognize that the given example warrant the use of modifier 25 (all answers to the question is 'yes'). The patient reported with a set appointment for the plug insertion and already had a diagnosis. Instead you would report:

• 9921x (Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components) for the E/M;
• modifier 25 linked to 9921x to show that the E/M and diagnostic endoscopy were separate services;
• 31231;
• 784.0 (Headache; Facial pain, Pain in head NOS) linked to the E/M;
• 478.19 (Nasal Obstruction) linked to 31231;
• 473.0 (Chronic Sinusitis, Maxillary) linked to 31231;
• 473.1 (Chronic Sinusitis, Frontal) linked to 31231.

Alternative situation: Suppose the patient did not complain about the headache and the Otolaryngologist has been treating him for chronic sinusitis for quite a while. The ENT documented just how the patient is feeling, the medications he is taking and immediately went to his endoscope and scoped the patient, not looking at any other anatomy or for any other  co-morbidities. In this case, the E/M represented the mini E/M associated with the diagnostic endoscope and is not separately billed. You would only bill the procedure:

• 31231
• 478.19 linked to 31231
• 473.0 linked to 31231
• 473.1 linked to 31231.

2. Look For the 'Oh By The Way' Moment

Minor surgical procedures always include pre-operative evaluation services such as assessing the site or problem, explaining the procedure and risks and benefits, and obtaining the patient's consent. The Centers for Medicare & Medicaid Services (CMS) has stated, time and again, that the initial evaluation is always included in the reimbursement for a minor surgical procedure and, therefore, is not separately billable.

Sometimes, however, the physician would perform additional E/M service when the patient adds to the service via an 'Oh by the way' during same visit as a procedure -- as described in our previous example. In this case, the E/M service would require physician work above and beyond the work usually linked with the procedure. You may bill this E/M service in addition to the procedure with modifier 25.

Warning: Not all payers will reimburse for the separate E/M service even if you comply with all the modifier 25 coding rules. When this happens, you should have your people appeal any denied claims. Make sure you have impeccable documentation from your physician as it will be put under a microscope when evaluated for an appeal. It is critical to see a separate history, exam and MDM as well as a procedure note. Medical necessity for the procedure must also be clear in the documentation. A second look by your payer could actually result in a decision to your favor.