Cardiology Coding Alert

Cardiologists who have slipped into the habit of routinely adding modifier -25 should beware: Auditing for overuse of this modifier will begin late this fall, according to the Office of the Inspector General (OIG).

In its plan of work, the OIG contends that physicians are deliberately billing this modifier in cases where it does not apply, for the sole purpose of increasing reimbursement.

The CPT explains that -25 is a modifier attached only to evaluation and management (E/M) codes that designate a Significant, Separately Identifiable E/M service by the Same Physician on the Same Day of the Procedure or other Service.

This modifier should be used to bill for a procedure or service that you normally couldnt get reimbursed for because it is considered part of another procedure or service, says Stephanie Gajic, CPC, director of clinical coding management and education at Cardiology of Georgia in Atlanta.

For example, suppose a patient comes in for his annual treadmill and the cardiologist discovers a new onset of mild carotid disease and addresses it. By appending modifier -25 to the office-visit code (99213), the physician can be reimbursed for both the stress test and an established office visit. Without the modifier, only the stress test code 93015 would be reimbursed, because it includes physician supervision, interpretation and report.

Many times modifier -25 is the appropriate code; the problem is that it has been used indiscriminately and inappropriately, Gajic says.

Dont Risk an Audit

Follow these tips to make sure your practice is in compliance.

1. Use modifier -25 for the unexpected and unrelated. Use this modifier if, on a day the cardiologist performed a procedure or service, the patients condition required a significant, separately identifiable E/M service.

For example, if, during the course of a patients annual treadmill, the physician discovers hypertension and addresses it, you would append modifier -25 to the office visit and code for the treadmill separately, explains Gajic.

You would use modifier -25 when the service or procedure performed was over and above, and unrelated to, the reason the patient came, she says.

2. Modifier -25 may also be used with diagnostic procedures. Take, for example, an established patient who presents in your cardiology office with chest pain. The cardiologist suspects unstable angina and, after having taken history and physical, wants to perform a cardiac catheterization to discover any physical abnormalities that may be causing the pain.

This E/M service appended with modifier -25 should be over and beyond the usual preoperative and postoperative care associated with the procedure that was performed, says Dianne Willard, MBA, RRA, CCS-P, practice manager, AHIMAs staff liaison for the Society of Clinical Coders.

Add modifier - 25 to the appropriate level of E/M service for established patients; in this case, 99212 [...]