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Cardiology Coding Alert

Reader Question:

Diagnostic Tests and Modifier -25

Published on Thu Nov 01, 2001

Question: The cardiologists in our office perform many echocardiograms and Doppler scans. They also charge an E/M on the same day. They maintain they dont need to append modifier -25 to the E/M because these tests are not considered procedures. Are they correct? How should these services be billed?

California Subscriber
 
Answer: Your cardiologists are correct in stating that diagnostic tests, such as echos, Dopplers and stress tests, are classified differently. For example, the global surgical package does not apply to diagnostic tests, which is why, in theory, modifier -25 (significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) need not be appended to E/M services performed on the same day.
 
There are other factors to consider. In 2000, CMS bundled most E/M services with the majority of diagnostic tests (including echos, Dopplers, etc.) to ensure that physicians did not charge separately for the preoperative evaluation that is included in the test.
 
To override the edit you had to append modifier -25  to the E/M service performed. The resulting uproar and confusion among carriers and physicians about how to implement these edits forced CMS to retract the edits two months later. In spite of the CMS retraction, there are continuing reports of carriers who want to see modifier -25 (or another modifier) appended to E/Ms performed on the same day as diagnostic tests. Most carriers, however, do not require modifier -25 in these situations.
 
Although the edits were retracted, most coding specialists agree that the criteria for using modifier -25 should be adhered to when billing for E/M and diagnostic tests on the same day. This means the cardiologist must perform and document a separate and significant E/M service. If the cardiologist only does a pretest evaluation, no separate E/M should be charged.

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