Advanced Search

Anesthesia Coding Alert

Details Count:

Follow Strict Guidelines to Collect Modifier -25 Pay

Published on Thu Sep 09, 2004

These 3 checkpoints can help your Medicare claims

Your pain management specialist conducted an E/M visit and performed a facet joint injection for the patient on the same day. You've coded the claim and have appended modifier -25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) to distinguish the services. But before you submit the claim to Medicare, Robin Fuqua, CPIC, anesthesia coder for Jose Feliz, MD, in Escondido, Calif., says to be sure that you meet the carrier's three requirements for reporting this modifier:

 

  • Check the level of service. The visit you're coding as an E/M service must be for reasons other than a simple 5-minute or less pre-op service that is assumed to be included in any visit. Help determine the level of service by asking yourself questions such as: Did the physician evaluate the patient for a new prescription or re-evaluate him to renew an old one? Did the physician address a new problem that the patient reported during that session? Did the physician order tests or schedule other procedures for later that day to treat another known problem?

     
  • Check all the diagnoses. You must have a separate, identifiable reason for the E/M service plus a separate diagnosis supporting the procedure that the physician performed that day. Did the doctor perform facet blocks (64475 and 64476) and write a prescription for muscle relaxants? If so, report both of the correct diagnosis codes: 724.8 (Other symptoms referable to back) for facet syndrome and 729.1 (Myalgia and myositis, unspecified) for the myofascitis evaluation.

     
  • Check the reports. Before you submit your claim with modifier -25, be sure the physician writes separate reports for the procedure (the operative report) and the E/M visit (the follow-up notes). They might sometimes complain about the extra paperwork, but they will be willing to cooperate when they realize how it affects their bottom line, Fuqua says.

    • Other Articles in this issue of

    Anesthesia Coding Alert

    View All