Cardiology Coding Alert

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.

Note: For invasive diagnostic or interventional procedures (heart catheterizations, peripheral vascular services, vascular interventions, and electrophysiology procedures), you're most likely to use modifier 25 when a patient presents for evaluation of certain signs or symptoms (such as chest pain) and the physician performs a procedure (such as heart catheterization) on the same day to help establish the diagnosis and/or to resolve the underlying condition.

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 [HHS Office of Inspector General] 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 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.

• 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.

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

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.

Scenario: The cardiologist performs an inpatient consultation for acute claudication/ischemia of the foot. The physician advises that the patient should undergo peripheral vascular angiography with possible intervention. Later that day, the cardiologist performs angiography and mechanical thrombectomy of the patient's popliteal artery.

In this case, you should include the following CPT codes and modifiers on your claim:

• 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 angiography's professional component, which is the only service the cardiologist 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.

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 place 75716 and 26 together on another line.