Radiology Coding Alert

Ignore this rule, and expect image-guided intervention denial frustrations

Mistakenly appending modifier 25 to a procedure instead of an E/M code is a simple enough error, but it can lead to plenty of appeals headaches.

Submit clean claims the first time with this step-by-step guide for properly reporting a modifier 25 interventional claim to Medicare.

Consider the OIG's Take on Modifier 25

You should always be concerned and careful when you use modifier 25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service), says John F. Bishop, PA-C, CPC, president of Bishop and Associates in Tampa, Fla. "The OIG has really cracked down on this modifier and collected huge sums of money for inappropriate coding." 

The OIG has homed in on three main problems with modifier 25 claims. Here's how to avoid them:

• Use 25 only with a significant and separately identifiable E/M service. The E/M should be above and beyond the usual preoperative and postoperative care associated with the procedure.

• Verify that you have complete documentation of both the procedure and the separate E/M. 

• Don't append modifier 25 if an E/M is the only service your physician provides the patient that day.

Bottom line: The physician must document "a separate identifiable service above and beyond what is considered inclusive in the procedure," says Sherry Wilkerson, RHIT, CCS, CCS-P, coding/compliance manager at CHAN Healthcare Auditors in St. Louis.

Resource: Read the OIG report on modifier 25, and its misuse, at http://oig.hhs.gov/oei/reports/oei-07-03-00470.pdf.

See What CMS Says About Global

CMS has clarified that you should use modifier 25 for an E/M service "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" (www.cms.hhs.gov/transmittals/downloads/R954CP.pdf).

Pitfall: Don't report a separate E/M for obtaining informed consent and the basic history and physical exam needed for a previously scheduled interventional procedure.

For image-guided interventions, you're most likely to use modifier 25 when a patient presents for evaluation of certain signs or symptoms and the physician performs a procedure on the same day to help establish the diagnosis and/or to resolve the underlying condition.

Apply Your 25 Savvy to This Example

Now that you know the rules, decide how you would report the appropriate CPT codes and modifiers on the CMS-1500 form for the following example.

Example: The radiologist performs an inpatient consultation for acute ischemia of the foot. The radiologist advises that the patient should undergo angiography with possible intervention. Later that day, the radiologist performs angiography and mechanical thrombectomy of the popliteal artery on the patient.

In this case, the CPT codes and modifiers you should use include:

• an E/M code, such as 99253 (Inpatient consultation for a new or established patient ...)

• modifier 25 attached to the E/M code to show that the service was significant and separate from the procedures performed the same day

• an angiography code, such as 75716 (Angiography, extremity, bilateral, radiological supervision and interpretation)

• modifier 26 (Professional component) appended to the angiography code (75716) to indicate that you're coding only the professional component of the angiography, which is the only service the radiologist performed that has separate professional and technical components

• popliteal artery thrombectomy code 37184 (Primary percutaneous transluminal mechanical thrombectomy, noncoronary, arterial or arterial bypass graft ...)

• a catheter placement code, such as 36247 (Selective catheter placement, arterial system; initial third order or more selective ...).

Note: Code 37184 has a zero-day global period, so according to CMS rules, you should append modifier 25 to any separate E/M service. Remember: A zero-day global and an XXX global (no global) are not the same.

Place the Codes Properly on CMS-1500

On the CMS-1500 form, you should enter:

1. The CPT codes in box 24-D under "CPT/HCPCS"

2. Modifiers 25 and 26 in box 24-D under "Modifier." Key: Put modifier 25 and 99253 together on one line, and put 75716 and 26 together on another line.