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 a minor related E/M service might surprise you, you probably know that modifier 25 submissions require a minimum of two codes. But that lesson escaped coders in 9 percent of the OIG's reviewed cases.

Modifier 25 was contained in 2.6 million claims even though the E/M visit was the only service the physician reported that day -- meaning the modifier was unnecessary. Without an accompanying initial service or procedure, you can't have a significant, separately identifiable service, experts say. When submitting claims consisting solely of an E/M code, make sure you don't include modifier 25.

Problem 3: Modifier 25 With XXX Procedures

The OIG report clarifies that physicians and qualified nonphysician practitioners (NPP) should use modifier 25 to "designate a significant, separately identifiable E/M service provided by the same physician/qualified NPP to the same patient on the same day as another procedure or other service with a global fee period." In other words, you should not use modifier 25 when the procedure that occurred on the same day has no global days.

The recent clarification "signals the need for a considerable change in billing protocol for most cardiology practices. Because the most frequent procedures (EKGs, echos, nuclear studies, and all but one of the pacemaker/defibrillator interrogation services) don't have a global period, we can say goodbye to modifier 25 for the overwhelming majority of claims," says Jim Collins, CPC, ACS-CA, CHCC, president of The Cardiology Coalition in Matthews, N.C.

Collins warns, however, that you can "expect denials in the immediate future, even with proper modifier 25 application/omission." 

The OIG audit finding revealed that "more than one-third of carriers have not conducted oversight related to modifier 25." This means payers are confused about this clarification as well.  "I've seen inappropriate denials from various payers when coders have appropriately left modifier 25 off of their claims," Collins says. For example, multiple Medicare carriers are inappropriately denying claims with follow-up visits (99214) and echos (93307, 93320 and 93325) -- all because the coder correctly left modifier 25 off 99214, Collins says.

Don't miss: CPT 2007 contradicts CMS' new policy. Your CPT 2007 book says you should attach modifier 25 to E/M services when you bill an E/M service the same day as the new anticoagulation manager services (99363-99364). "Bottom line is CMS, the OIG and the AMA are all in conflict with each other about modifier 25," Collins says. "In their eyes, the physicians are the ones submitting claims incorrectly."

Another part of the problem may be that "no global" by CMS' definition doesn't always mean all procedures with global days classifications of XXX (Global surgical rules do not apply). 

The misunderstanding is that zero global days may still have a global. "Due to the National Correct Coding Initiative (NCCI) 7.2 and higher, some carriers have attached a minor E/M to procedures with XXX global designations," says Barbara Cobuzzi, MBA, CPC, CPC-H, CPC-P, CHCC, president of CRN Healthcare Solutions, a coding and reimbursement consulting firm in Tinton Falls, N.J.

In other words: A carrier taking the wording from NCCI will include a small E/M (HEM) with an XXX procedure, despite this procedure not having a global period and therefore no official E/M associated with it. "NCCI overrode the global definition and applied a small global on the day of zero-day global procedures," Cobuzzi says.

Best bet: Keep checking with your payer to see whether you should include modifier 25.

Extra: Want to be vigilant about avoiding OIG scrutiny? The OIG has recently released its 2007 Work Plan. You can read it at http://oig.hhs.gov/publications/docs/workplan/2007/Work%20Plan%202007.pdf.