Pulmonology Coding Alert

When -25 doesn't cure your E/M pay problems, modifier -57 may do the trick

If you want to recoup reimbursement for your modifier -25 claims, make sure you can identify your physician's E/M services separately from his other procedures, such as a bronchoscopy performed on the same patient on the same day as another E/M procedure. And if the physician makes the decision for surgery during the E/M visit, choose modifier -57 instead of -25.

Bronchoscopy is a procedure that allows the physician to use a bronchoscope (fiberoptic or rigid) to enter the larynx, trachea and bronchi, says Alan L. Plummer, MD, professor of medicine in the division of pulmonary, allergy and critical care at the Emory University School of Medicine in Atlanta. Once the physician establishes entrance, he says, the physician looks for abnormalities, and he biopsies any suspicious lesions and obtains washings or lavages specimens for diagnostic purposes.

Example: A patient comes to your practice for a follow-up visit. He has chronic obstructive pulmonary disease (COPD) and he's an ex-smoker. He informs your physician that he has a new complaint of hemoptysis, and the physician takes a chest x-ray. The x-ray indicates a suspicious shadow in the right hilar area. The physician decides to perform a bronchoscope on the patient the same day, Plummer says.

Coding options: You could code the office visit with the E/M code for a low to moderate problem (99214, Office or other outpatient visit ...) since the physician identified a new problem at a routine follow-up visit. You should add modifier -25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) to indicate that the physician performed a separate procedure from the E/M visit on the same day of the examination. You should code the bronchial biopsy with 31625 (Bronchoscopy, rigid or flexible, with or without fluoroscopic guidance; with bronchial or endobronchial biopsy[s], single or multiple sites).

Here are three easy questions to ask yourself -- with answers from the experts -- to help guide you on the road to hassle-free use of modifier -25.

CMS specifies that all procedures have an inherent evaluation and management component. Private payers also assume there's some inherent E/M visit built into the reimbursement for procedure codes, because most procedures require the physician to perform a "preoperative" history and physical.

This is why you need to be careful not to overuse modifier -25. Don't append modifier -25 just because your pulmonologist spoke with the patient before doing the procedure, says Brenda W. Messick, CPC, a coding specialist in Atlanta.

For Medicare, to properly code using modifier -25, the physician must perform an E/M service that is separate and identifiable from any minor procedure, coding experts say. Your documentation must include the E/M service as well as the procedure, says Robin Trahon, CPC, coding specialist with Brigham and Women's Physician Organization in Brookline, Mass.

For example: A patient comes to your office for the first time, and your physician performs an E/M and gains an extensive health history. After the physician completes the E/M service, he determines that the patient has fluid between the pleura and the chest wall. As a result, the physician must perform thoracentesis to drain this fluid, Trahon says.

In this example you can bill for both the E/M procedure and the thoracentesis. The completed procedure should have global days of zero or 10 in order to use modifier -25 on the E/M code.

You should include all the needed E/M documentation, including the plan to examine and collect an extensive health history. Then you want separate documentation for the thoracentesis to show that you have reason to report a complete E/M separately. The repair documentation procedural note can be either on the same sheet or on a separate piece of paper. You can provide the mini-operative report of the repair that tells how the pulmonologist completed the procedure in detail.

Exception: If the patient's visit/appointment was made for the sole purpose of doing a thoracentesis, and not for the physician to manage or address any other issues, then you should bill only for the thoracentesis (32000, Thoracentesis, puncture of pleural cavity for aspiration, initial or subsequent) without reporting an E/M code or modifier, Trahon says.

Tip: When asking yourself whether a procedure stands alone, separate the E/M notes from the procedure documentation in your medical record. If a reviewer could look at your medical notes and clearly see that the physician completed two separate and independently identifiable services, you can append modifier -25 for Medicare minor procedures.

Don't miss: Private payers typically bundle the E/M with the procedure, regardless whether it is separately identifiable and has modifier -25 appended.

You may think that in order for an E/M service to be separately identifiable, the service must have a separate diagnosis. Not true.

CPT states that an E/M service may be prompted by a symptom or condition that requires a procedure, but the procedure must be separate from other services your pulmonologist performed for the initial symptoms or conditions. You don't necessarily have to have another diagnosis.

For example: If a patient comes in for shortness of breath, and the physician performs an E/M visit and a chest x-ray, you should report a diagnosis for shortness of breath for both the E/M and chest x-ray, Corcoran says. You could still report both if you put -25 on the E/M, Corcoran says.

Warning: Never append modifier -25 to the procedure code, only to the E/M code. You may encounter situations, such as the one described above, in which the same diagnosis will be the reason for both the E/M visit and the procedure, says Tina Landskroener, CCS-P, of Total Healthcare Compliance in Las Vegas.

Modifier -57 (Decision for surgery) applies to E/M services also, but you should not use this routinely for procedures the pulmonologist performs with E/M visits.

For Medicare you should use modifier -57 only if the physician performing the major surgery decides that the patient needs a surgical procedure the day before or the day of the procedure and the procedure has a global period of 90 days. Modifier -57 is allowed by Medicare to represent the surgeon's work required to reach the decision for surgery for a major procedure. On the other hand, you should use modifier -25 to represent a separately identifiable E/M service that the physician performed during the zero- to 10-day global period of a minor procedure.

Reimbursement tip: Every carrier is different, and not all of them follow the coding standards for using modifier -25. "Sometimes it's best to contact those carriers that keep denying you and find out how they want it billed. If a carrier ever tells you anything that is directly against an accepted CPT/ICD-9/HCPCS coding standard, then ask for it in writing," says Jamie Darling, CPC, of Graybill Medical Group in Escondido, Calif.

Note: To identify the global day for each service, refer to the 2004 Physician Fee Schedule located in Addendum B of the Federal Register: http://www.access.gpo.gov/su_docs/fedreg/a031107c.html.