Pulmonology Coding Alert

Modifier -25 is an important coding ally if a physician performs a consultation (evaluation and management [E/M]) that results in the physician performing a thoracentesis (or other service) on the referred patient. He or she can bill for the procedure; and then add a modifier -25 to the E/M service.

If I do a consult and then a thoracentesis, I would put modifier -25 on the consultation code (99241-99245) and then bill the procedure code (32000-32002). Using -25 indicates that you didnt do the consult in order to do the thoracentesis. The two services, the first of which is a consultation and the second a procedure, are separately identifiable services and reimbursement should be sought for each, explains Walter J. ODonohue, MD, FCCP, representative to the American Medical Associations CPT Advisory Committee for the American College of Chest Physicians.

ODonohue offers the example of when a patient visits him suffering dyspnea (786) and right chest pain (786.50). After an exam reveals they have signs of fluid in their chest and the chest x-ray shows they have a right pleural effusion (511.9), I would want to know why its there. Thats when I would do a thoracentesis.

Or perhaps another physician has been treating a patient with pneumonia (486) and a chest x-ray shows an effusion? If the patient is then referred to him for evaluation, and he sees the patient the same day of the referral and performance of the thoracentesis, ODonohue says he attaches modifier -25 to his E/M consult service.

It could become a problem, says ODonohue, on an outpatient bronchoscopy (31622-31656) where you have to do a health and physical exam before the bronchoscopy. Usually, the health and physical is bundled with the bronchoscopy. But, continues ODonohue, what if you see a patient that morning for consultation because hes coughing up blood? A consult is done, you work him up, do a chest x-ray and see a mass. As a result, that afternoon you do a bronchoscopy. You would bill the E/M service with the modifier -25, and then bill the bronchoscopy. Separate encounter, same day.

Diana Emm, a biller with Eastern Ohio Pulmonary Consultants, in Boardman, Ohio, cites an example of when modifier -25 would not be used. If a patient comes into our office with pleural effusionweve seen [the patient] before and its gotten worseand we know were going to do a thoracentesis because of that pleural effusion, we dont use the modifier -25 because we already know [the patient] is coming in for that.

But if the patient is new, says Emm, We go ahead and code the E/M with modifier -25 and the procedure unmodified. If we dont have any history, we go ahead and get the history, which would be your E/M service code (99201-99205). Then we would make the decision at that point whether or not the patient needs to [receive a thoracentesis].

Barbara Cobuzzi, CPC, CHBME, president of Cash Flow solutions, a physician reimbursement consulting firm in Lakewood, N.J., says, In any physicians office, the consultation code is 99241-99245assuming another doctor has asked for their opinion.

Cobuzzi makes the distinction for an inpatient consult, as well. If another doctor, a cardiologist for example, requests the physicians opinion, the consulting codes are 99251-99255. Again, Cobuzzi lists another important distinction: If its an established patient and no opinion is being sought for that patient and the physician is being requested to evaluate her lung condition, [the visit] would be coded 99231-99233 (subsequent hospital care).

Modifier -25 Can Enhance Reimbursement Levels A physician may need to indicate that on the same day a procedure or service identified by a CPT code was performed, a patients condition required a significant, separately identifiable evaluation and management (E/M) service above and beyond the other service provided. Possibly the E/M service resulted from symptoms or a condition for which the procedure or service later was provided. Modifier -25 can be used with other E/M codes as well, as long as it indicates a significant, separately identifiable procedure or other service on the same day. Melissa Winans, an office-billing manager with Ohio Valley Pulmonary Services, a billing and reimbursement service for a pulmonary practice in Marietta, Ohio, says the modifier -25 readily applies to office visit consultations at that practice. For example, if the patient comes into the office for a pulmonary function test and also receives an EKG, says Winans, we will use modifier -25 on the office visit (99213-99215), which tells the auditor that the patient has additional testing that didnt pertain to that office visit. If you dont include the -25 modifier, the insurance carrier will include the EKG procedure with your office visit, and you wont get paid for it. Editors note: CPT 2000 cautions that when an E/M service results in a decision to perform surgery, modifier -25 is not applicable. Instead, it recommends that you consider modifier -57 (decision for surgery) for possible application