Cardiology Coding Alert

Find out why this clarification is good news for your practice

Just because auditors are targeting modifier 25 doesn't mean you should cut out your use of this tool. CMS recently clarified how you should use modifier 25. See if these common cardiology scenarios do or do not merit its use.
  
Recent reports of the Office of Inspector General (OIG) targeting claims containing modifier 25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) have raised concern in cardiology practices.
 
Bottom line: "Every coder should always be concerned and reverent when using modifier 25," says John F. Bishop, PA-C, CPC, president of Bishop & Associates  Inc. in Tampa, Fla. "The OIG has really cracked down on this modifier and collected huge sums of money for inappropriate coding." 
 
Best bet: You should only use modifier 25 when your cardiologist provides a significant and separately identifiable E/M service on the same day as a procedure with a global period, says Jim Collins, CPC, ACS-CA, CHCC, CEO of the Cardiology Coalition in Matthews, N.C. You can read the CMS clarification (implementation date Aug. 1) at www.cms.hhs.gov/transmittals/downloads/R954CP.pdf.
 
Scenario 1: Study This Same-Day Stress Test Example

A cardiologist sees a patient for an E/M service and decides to perform a stress test, having room on his schedule for a stress test on the same day.
 
"Because the recent CMS clarification states that you should only apply modifier 25 with an E/M code when a procedure has a global period, you should not use a modifier 25 in this situation," Collins says. "The stress test does not have a global period."
 
Because the E/M service is significant and separately identifiable, you can still report both the E/M and stress test codes. You simply do not need modifier 25 appended to the E/M code.
 
To report the stress test, you should use the following codes: 93016 (Cardiovascular stress test using maximal or submaximal treadmill or bicycle exercise, continuous electrocardiographic monitoring, and/or pharmacological stress; physician supervision only, without interpretation and report), 93018 (... interpretation and report only, if performed in the hospital) and 93015 (... with physician supervision, with interpretation and report, if performed in the office).

Scenario 2: Learn About Image-Guided Interventions

The cardiologist sees an inpatient in consultation for acute ischemia of the foot. The cardiologist advises angiography with possible percutaneous intervention. Later that day, the patient undergoes angiography and mechanical thrombectomy of the popliteal artery.
 
Report the inpatient consultation (99251-99255) with modifier 25, as well as the angiogram and thrombectomy. "If the cardiologist makes the decision to perform the cath on the same day, you should bill for this service separately," says Melissa Bedford, coding specialist at Austin Heart in Austin, Texas.
  
Heads up: 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.
  
The major conclusion of the OIG study was not that modifier 25 was simply inappropriate. "Medical reviewers found that providers did not document the E/M services and/or procedures for 27 percent (116/431) of the sampled claims received from providers," Wilkerson says
 
Rule of thumb: For image-guided interventions, you're most likely to use modifier 25 when a patient presents for evaluation of certain signs or symptoms, and on the same day, the physician performs a procedure to help establish the diagnosis and/or to resolve the underlying condition.
  
Caution: Don't report a separate E/M for obtaining informed consent and the basic history and physical exam needed for a previously scheduled interventional procedure. "Hospitals require history and a physical upon admission, but many times you cannot bill for these because they are part of the global package," Bedford says.

Scenario 3: Ask if ECGs Have Global Days

An established patient comes in complaining of palpitations (785.1) and light-headedness (780.4). The provider performs a complete cardiac workup and orders a same-day, in-office echocardiogram.
 
You should ask, does the echo code (93307, Echocardiography, transthoracic, real-time with image documentation [2D] with or without M-mode recording; complete) have a global period? The answer is no. Therefore, you do not need to append modifier 25 to your E/M code. 
 
Note: As for reporting the echocardiogram, you may need to add additional codes, depending on the equipment and the images the physician obtained. These additional codes could include +93320 (Doppler echocardiography, pulsed wave and/or continuous wave with spectral display; complete [list separately in addition to codes for echocardiographic imaging]) or +93325 (Doppler echocardiography color flow velocity mapping [list separately in addition to codes for echocardiography]).
 
Report the office visit with an E/M code, such as 99214 (the level would depend on the physician's documentation).
 
Good news: "Prior to this CMS clarification, payers had varying standards as to when you should appropriately use modifier 25," Collins says. "Many would not allow separate payments for E/M services cardiologists provide on the same day as simple tests such as echocardiograms or Coumadin testing."
 
Want more? Upcoming issues of Cardiology Coding Alert will feature modifier 25 and modifier 59 scenarios that your peers have submitted. Have a modifier mystery you want our experts to solve? E-mail the example to the editor at suzannel@eliresearch.com
 
Get more advice by enrolling in The Coding Institute's audioconference "The Scary Truth About Modifier 25 and 59 Misuse: Is Your Practice at Risk?" Find out how misuse has been flagged and make sure your practice is following proper modifier guidelines to stay out of payer scrutiny.