Cardiology Coding Alert

You may still need to apply modifier 25 with XXX global-day procedures You've only just started the year 2007, but now is not the time to be lax in how you report modifier 25. You can prevent paybacks by avoiding the following three problems that will land your claims in the OIG's error rates.

Hard facts: In a November 2005 study, the HHS ffice of Inspector General cast a spotlight on 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), and the results weren't pretty. The OIG found a 35 percent error rate for modifier 25. Problem 1: No Separate E/M HEM Modifier 25's descriptor of a significant, separately identifiable E/M service isn't at the root of most of the claim problems. Only 2 percent of improperly coded modifier 25 claims involved E/M services that weren't significant and separately identifiable, according to the OIG.

Reality: Some 27 percent of modifier 25 claims had documentation of the procedure, but not the separate E/M. For example: Documentation showed that the cardiologist provided a echocardiogram for a patient on the same day as an office visit but offered no information about the separate E/M service (such as 99201-99215, Office or other outpatient visit for the evaluation and management of a new or established patient).

"If a patient comes to see the cardiologist due to multiple problems, for one of which the cardiologist wants to order an echocardiogram, the visit is separately identifiable. The reason is the cardiologist addressed one or more problems that required separate medical decision-making," says Heather R. Stecker, CPC, director of compliance and charge entry at Cardiology Consultants of Philadelphia PC.

The OIG wants CMS to educate providers and reinforce the requirement that you should use modifier 25 only with services that are "significant, separately identifiable" and "above and beyond the usual preoperative and postoperative care associated with the procedure."

Best bet: When using modifier 25, you should remember this maxim: "If you don't have a HEM, you can't bill an E/M," says Laureen Jandroep, OTR, CPC, CCS-P, CPC-H, CCS, CPC-EMS, CodeRyte Inc. coding analyst and coding review teacher.

Here, "HEM" stands for "history, exam and medical decision-making." All procedures include some service related to patient evaluation and management, but a separate E/M should include its own HEM, Jandroep says.

In other words, "the physician needs to determine whether the problem is significant enough to require additional work to perform the key components of the problem-oriented E/M service," says Christina Neighbors, MA, CPC, a cardiology charge capture reconciliation specialist for Franciscan Health Systems in Tacoma, Wash. Problem 2: Modifier 25 With Single-Code Claims Although the news that all procedures contain [...]