Pulmonology Coding Alert

Private payers may drop the modifier requirement for medicine/service claims You finally have a fail-safe policy to stop the nagging doubt over whether you should append modifier 25 to the E/M service on a claim that also involves a medicine code. CPT: Many Medicine + E/M Claims Don’t Require 25 When you perform an office visit that is separate and distinct from a medicine service (meaning a procedure listed in the Medicine section of CPT), “the E/M code does not typically require modifier 25 (Significant, separately identifiable E/M service by the same physician on the same day of the procedure or other service),” says Richard H. Tuck, MD, a nationally recognized coding speaker. “You will not find any language to that effect in CPT or CPT Assistant.”

But your office may be in the habit of automatically entering 25 on all claims for same-day office visits with associated medicine services. Physicians have been increasingly using modifier 25 because payers have recognized the modifier and paid claims coded in that manner, Tuck says. “Thus, the modifier has become used more frequently than rules necessarily dictate.”

Tuck says the following medicine services are among those that CPT does not require to have modifier 25 on the E/M service code (such as 99201-99215, Office or other outpatient visit for the E/M of a patient …):

• evaluation of patient’s use of an inhaler (94664, Demonstration and/or evaluation of patient utilization of an aerosol generator, nebulizer, metered dose inhaler or IPPB device)

• airway inhalation treatment (94640, Pressurized or nonpressurized inhalation treatment for acute airway obstruction or for sputum induction for diagnostic purposes [e.g., with an aerosol generator, nebulizer, metered dose inhaler or intermittent positive pressure breathing (IPPB) device]).

CMS Echoes CPT Policy Recently, the Centers for Medicare & Medicaid Services backed this less-use policy via a much-needed clarification. New guidance: As of Aug. 20, you should only use modifier 25 when the physician provides a significant and separately identifiable E/M service on the same day as a procedure with a global period, says Jim Collins, CPC, CHCC, president of Compliant MD Inc. in Matthews, N.C.

CMS Transmittal 954 states modifier 25 “shall be used when the E/M service is above and beyond the usual pre- and postoperative work of a procedure with a global fee period performed on the same day as the E/M service.” Otherwise, “E/M services provided on the date of the procedure are inclusive unless a separately identifiable E/M service is provided on the same day,” says Kathy Pride, CPC, CCS-P, director of consulting and training for QuadraMed in Reston, Va.
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