Anesthesia Coding Alert

Documentation explains the story, increases specificity

Every coder knows that appending modifiers can help you report services more accurately and get appropriate reimbursement. The down side is that wading through the choices can bog you down, especially if you're new to pain management coding. Here, you get the lowdown on three common pain management modifiers for reporting multiple services, along with some expert coding tips.

Pair Modifier -25 With E/M Service

If your physician performs an E/M service on the same date that he performs another procedure for the patient, you'll want to get to know modifier -25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service).
 
Many pain management coders report modifier -25 success when new patients present to their practices. Example: The pain specialist completes a history, physical and medical decision-making (components of an E/M visit) to determine whether the patient is a good candidate for a requested nerve block and will be able to tolerate it well. If the physician administers the nerve block the same day, report the appropriate E/M visit code with modifier -25 appended, plus the code for the nerve block.
 
"You can bill the E/M only if this is the first time you've seen the patient and a decision for a procedure was made at this session," says Carolyn MacDonald, CPC, coding manager for New England Health Care Foundation/New England Medical Center Hospitals in Boston. "If the physician has already made the decision to do the procedure, you cannot bill for a pre-op E/M exam."
 
The physician may also perform the E/M visit later (in a different "session") on the same day; this can range from an actual procedure such as a separate injection to other services such as medication refills.
 
"This happens all the time in our office, and we generally get paid," says Robin Fuqua, CPIC, anesthesia coder for Jose Feliz, MD, in Escondido, Calif. "Just follow Medicare's requirements if you expect to get paid." (See "Follow Strict Guidelines to Collect Modifier -25 Pay" on page 19 for more on this.)

Modifier -51 Signifies Extra Services

You already know to append modifier -25 if the physician performs an E/M service and another procedure during the same day. But what if he performs multiple procedures (not an E/M service) during the same session? That's when you should append modifier -51 (Multiple procedures) instead.
 
"We use modifier -51 most often when we're billing multiples of the same injection," Fuqua says. "In California, workers' comp carriers still use 20550 (Injection[s]; single tendon sheath, or ligament, aponeurosis [e.g., plantar "fascia"]) for trigger point injections. So when we inject multiple muscle groups, we list each one separately. The first code has no modifier, and all additional codes have modifier -51."
 
Caution: Don't assume that you can automatically bill each service separately just because the physician performs them during the same session. The National Correct Coding Initiative edits often bundle related services so you can't bill them separately. You can sometimes separate these edits and still use modifier -51 to report each service, but carriers keep a close eye on these situations. When you report modifier -51, the carrier reimburses 100 percent for the first procedure and 50 percent for the second.
 
Because of this, some coders caution against reporting modifier -51 too frequently - they would rather err on the side of caution than risk audits for seeming to unbundle procedures too often. Other coders aren't so concerned.

"Medicare in Massachusetts doesn't require modifier -51," MacDonald says, "so they don't even look at it. I have no problems with claims using modifier -51."

Code Distinct Services With Modifier -59

The key when reporting modifier -59 (Distinct procedural service) is having documentation to prove that the second service is distinct from the original one. This includes an explicit diagnosis supporting the medically necessity of reporting the additional service.
 
Modifier -59 also reports additional services, which means some coders confuse it with modifier -51 until they learn to correctly report both. Many pain management coders opt for modifier -59 over modifier  -51 if the situation merits it. Just be sure you have the documentation to support using modifier -59, MacDonald says (with information specifying the times of each session, that the physician treated a different anatomic site, etc.).
 
Coders often report modifier -59 when the physician places an epidural catheter (62319, Injection, including catheter placement, continuous infusion or intermittent bolus, not including neurolytic substances, with or without contrast [for either localization or epidurography], of diagnostic or therapeutic substance[s] [including anesthetic, antispasmodic, opioid, steroid, other solution], epidural or subarachnoid; lumbar, sacral [caudal]) for postoperative pain relief. If you append modifier -59, the insurer will note that the physician did not use the catheter as the mode of anesthesia during the original procedure.
 
Coders also rely on modifier -59 if the physician evaluates a patient for a different type of pain management because a postoperative block did not work. You should bill for the initial injection, MacDonald says, but if the insurer bundles the second injection with the first, you should append modifier -59 to the procedure code to show that it was a separate service.
 
Fuqua always uses modifier -59 when the physician performs two different types of procedures on the same date of service: for example, if the physician administers a cervical epidural (62310, Injection, single [not via indwelling catheter], not including neurolytic substances, with or without contrast [for either localization or epidurography], of diagnostic or therapeutic substance[s] [including anesthetic, antispasmodic, opioid, steroid, other solution], epidural or subarachnoid; cervical or thoracic) with fluoroscopy (76005, Fluoroscopic guidance and localization of needle or catheter tip for spine or paraspinous diagnostic or therapeutic injection procedures [epidural, transforaminal epidural, subarachnoid, paravertebral facet joint, paravertebral facet joint nerve or sacroiliac joint], including neurolytic agent destruction) and a trigger point injection (20552, Injection[s]; single or multiple trigger point[s], one or two muscle[s]] or 20553, ... single or multiple trigger point[s], three or more muscles).
 
Clarify: In the above example, remember that the physician must document separate diagnoses for each injection, such as 722.0 (Displacement of cervical intervertebral disc without myelopathy) for the cervical epidural and 728.85 (Spasm of muscle) for the trigger point injections. You must fully document each injection on the operative report so you can fight any insurer's attempt to bundle them together.
 
Dealing with carrier rejections can be one of the biggest challenges when reporting modifier -59. If your insurer denies your modifier -59 claim, you may want to appeal the denial and send a copy of your operative note with your appeal, MacDonald says.  As long as you maintain the necessary documentation to support your claim, you can confidently append modifier -59 to your claims and expect appropriate reimbursement.