Otolaryngology Coding Alert

If you don't use modifier -25 correctly, you might face a long appeal process, refund requests, payment refusals, or, even worse, an audit. As long as you can demonstrate that your E/M encounter and your surgical procedure are separately identifiable, you'll be on the right track to additional reimbursement. The HHS Office of Inspector General plans to scrutinize claims that include modifier -25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) this year, so you shouldn't append this modifier unless you're sure that your visit meets all of its criteria. Follow these three simple steps from the experts to determine whether you've made your case for your modifier -25 claims. Prove That the Service Is Separately Identifiable CMS dictates that all minor procedures, from simple injections to common diagnostic tests, include an inherent E/M component.

Medicare will not pay you for an additional E/M service unless you can demonstrate that it is significant and separately identifiable, and that it goes above and beyond the E/M service you would normally provide as a part of the procedure.

Watch out: Some practices define "significant" to mean that the E/M visit with a -25 modifier must be at least a level-four or -five code (such as 99204 or 99215, Office or other outpatient visit for the evaluation and management ...), but the September 1998 CPTAssistant states, "To use modifier -25 correctly, the chosen level of E/M service needs to be supported by adequate documentation for the appropriate level of service. ... modifier -25 is not restricted to any particular level of E/M service." Don't Bill E/M Without HEM So you should append modifier -25 to your E/M code if the physician believes that he performed an E/M service that was completely independent of the procedure. "I always say, if you don't have an HEM (history, exam and medical decision-making), you don't have an E/M," says Laureen Jandroep, OTR, CPC, CCS-PCPC-H, CCS, director and senior instructor for the CRN Institute, an online coding certification training center. "There should be clear documentation of the HEM, in addition to any notes about procedures performed."

Tip: To demonstrate that your E/M service qualifies as an independent evaluation, you should physically separate the E/M notes from the procedure documentation in the medical record. The physician should document the HEM in the patient's chart and record the procedure notes on a different sheet attached to the chart. Using this documentation method, a reviewer can clearly identify the two services, each of which you have individually supported with documentation. Example: Suppose your patient complains of an earache (388.70). The otolaryngologist performs a history and physical and decides [...]