Urology Coding Alert

Make sure you understand modifier -25

Yes, modifier -25 will get you reimbursed for E/M services performed at the same patient encounter as other procedures. But can you bill for as many E/M procedures as the day will allow? Before you start fantasizing about spending all that extra income, repeat after me: "separately identifiable," "separately identifiable."
 
A patient presents with torsion of testis (608.2), requiring a repair (CPT 54600 , Reduction of torsion of testis, surgical, with or without fixation of contralateral testis). During the procedure, concerns are raised about testicular cancer because a lump is present. The physician may bill for a separate E/M service for the procedure and a separate E/M for the cancer with modifier -25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service).
 
Use of modifier -25 rests on how you - and more important, carriers - define the term "separately identifiable." Some carriers are clarifying what they mean by separately identifiable, which requires great care when you decide whether to bill an E/M visit with a minor procedure. Big Brother Is Watching Care in this area is very important right now. The Office of the Inspector General of the Department of Health and Human Services is particularly interested in E/M procedures in calendar year 2003. According to the OIG's Fiscal Year Work Plan (available at www.oig.hhs.gov/publications/docs/workplan/2003/2-CMS%20FY03.pdf), the OIG is now "assessing the adequacy of controls to identify physicians with aberrant coding patterns, specifically coding disproportionately high volumes of high-level evaluation and management codes that result in greater Medicare reimbursement."
 
The rules: CMS stated in the Nov. 2, 1999, fee schedule announcement in the Federal Register that "every procedure has an inherent E/M component." This announcement says that the "significant, separately identifiable service would need to be documented in the medical record" whenever using modifier -25. "In other words, we want to prevent the practice of physicians reporting an E/M service code for the inherent evaluative component of the procedure itself."

'It's a Judgment Call' But exactly what that inherent evaluative component consists of is not spelled out. "It's a judgment call," says  Michael A. Ferragamo Jr., MD, FACS, Clinical Assistant Professor of Urology, State University of New York, Stony Brook, New York.
 
"Modifier -25 says the urologist is doing a significant, separately identifiable service E/M on the same day he does a procedure," he says. "Modifier -25 gets attached to the E/M service, not the surgical service. It goes on either a 0-day global or 10-day global procedure performed on the same day as an E/M service is performed."
 
Kimberly Hodges, CPC, an office manager at a practice in Florida, says she uses modifier -25 often, usually [...]