Urology Coding Alert

 A new CMS transmittal may mean modifier 25 claims will be targeted Determining when to append modifier 25 is already difficult -- and thanks to a new transmittal from the Centers for Medicare & Medicaid Services, your modifier 25 claims may be even more of a hassle. Now's the time to sit up and pay attention to make sure your physician's documentation supports modifier 25. Take Note of 3 Key Points Your documentation supporting the use of modifier 25  (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) will be under heavy scrutiny soon, judging from Transmittal 954, issued May 19 by CMS.
 
Clarification 1: CMS has added the word "usual," so the guidelines for modifier 25 now read: "a significant, separately identifiable E/M service that is above and beyond the usual pre- and postoperative work for the service." The addition is just meant to emphasize that any extra E/M service must be "above and beyond" the typical pre-op or post-op work, says Quinten Buechner with ProActive Consultants in Cumberland, Wis.
 
Clarification 2: Transmittal 954 clarifies and reemphasizes that you don't need a different diagnosis for the E/M service and surgery to be able to use modifier 25. Remember, however, that many private carriers demand separate diagnoses if you expect them to pay for the E/M service as well as the procedure.
 
Clarification 3: You'll now also need to make sure that you have appropriate documentation that proves the medical necessity of the separate same-day E/M service your urologist provided. You don't need to submit this documentation with the claim, but it must be available upon request. Stress 'Significance' in Documentation The guidelines for using modifier 25 haven't actually changed, says Stacie L. Buck, RHIA, CCS-P, LHRM, vice president of Southeast Radiology Management in Stuart, Fla. "CMS is issuing clarification in light of the findings in the OIG's report on modifier 25." The Office of Inspector General found a 35 percent error rate for modifier 25 -- and $538 million in improper payments -- in its sample of claims from 2003.
 
But it's safe to say your modifier claims will be under more scrutiny. "I strongly believe that providers will see more and more claims with 25 subjected to pre- and post- payment review because of the OIG findings," Buck adds.
 
Be proactive: All procedures, from simple injections to common diagnostic tests, include an "inherent" E/M component, according to CMS guidelines. Therefore, any E/M service you report separately must go "above and beyond" the minimal evaluation and management that normally accompanies such a procedure.
 
When you're considering whether you should append modifier 25 to an E/M service code when your [...]