Dermatology Coding Alert

Here's why you should always append your postoperative modifiers first.

When your dermatologist performs an E/M service within a major surgery's 90-day global period, you may think you have modifiers 25 and 57 down pat -- but the similarly relevant modifier 24 can interfere with your routine.

Tackle the following tricky cases, and you won't be wasting precious time on appeals.

A patient undergoes 17106 (Destruction of cutaneous vascular proliferative lesions [e.g., laser technique]; less than 10 sq cm) for his left arm. Before the 90-day postoperative period ends, he complains of a rash on his right leg. Consequently, the dermatologist performs an evaluation for this new problem.

In this case, you should use modifier 24 (Unrelated evaluation and management service by the same physician during a postoperative period) to indicate an unrelated E/M during the global period, says Pamela J Biffle, CPC, CPC-I, CCS-P, CHCC, CHCO, owner of PB Healthcare Consulting and Education Inc. in Watauga, Texas.

Rationale: This modifier tells your payer that there is a new problem that warrants an evaluation, and therefore is not included in the global surgical package of the previous procedure. Also, modifier 24, like 25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service), has no restriction as with the level of E/M code as long as it meets medical necessity and all its components, or if the code is timebased.

Learn the lesson: Experts agree that you should use modifier 24 more often than you think. If you failed to file a claim every time for an office visit with this modifier, you would not get paid for the office visit alone -- and that means you lose out on thousands of dollars.

Scenario 2: Mohs Procedure? Pair Up 25 and 57

Suppose a patient comes in for a consultation and has a Mohs procedure (17313, Mohs micrographic technique, including removal of all gross tumor, surgical excision of tissue specimens, mapping, color coding of specimens, microscopic examination of specimens by the surgeon, and histopathologic preparation including routine stain[s] [e.g., hematoxylin and eosin, toluidine blue], of the trunk, arms, or legs; first stage, up to 5 tissue blocks) done on the same day. Modifiers 25 and 57 (Decision for surgery) are the most reliable modifier combination for these kinds of cases, says Margie Knox, LPN, CDC of Columbia Skin Clinic, S.C. The Mohs procedure has a 90-day global closure.

Description: Modifier 25 denotes that the E/M service is separately identified from any procedure rendered on the same day. Meanwhile, when a surgeon decides to perform a major surgery (with a 90-day global period) and provides it that same day, append modifier 57 to the E/M code.

Consequence: If you failed to append modifier 57 to the E/M code, the payer would include the E/M service into the global surgical package. Again, this means grave loss in reimbursements.

Example: A patient presents to your dermatologist complaining of a lump and discoloration on his nose. The dermatologist performs an expanded problem-focused history and examination (99213, Office or other outpatient visit for the evaluation and management of an established patient...) and decides to perform a biopsy and pathology on that same day (11100, Biopsy of skin, subcutaneous tissue and/or mucous membrane [including simple closure], unless otherwise listed; single lesion; and 88331, Pathology consultation during surgery; first tissue block, with frozen section[s], single specimen). The biopsy result reveals basal cell carcinoma, so the physician decides to go ahead with the Mohs procedure (17313) that same day.

Action: Submit the E/M code with appended modifier 25. Keep in mind, a few payers may want modifier 57 for a major procedure. Put these codes together and you have 99213-25-57, 11100-59, 88331, 17313 (plus any appropriate closure such as tissue transfer, graft).

You may find yourself in situations where you need to combine the forces of 24 and 25 to avoid a denial on a claim. The patient comes for an office visit that is absolutely unrelated to the surgery and for which there is a postoperative in place. Also, the physician performs a minor surgery (such as a biopsy, destruction) at the time of the visit that is unrelated to the global procedure. You would append 24 and then 25 to the E/M code.

Tip: Always use the postoperative modifier first, before you use other modifiers. Most computers sequence their edits, putting the postoperative period edits as the primary edit.

The three modifiers discussed serve their own important roles in E/M. They all work well on their own or with each other, provided you do not mix them up. The key is to know each one's main function so as not to put it out of place.

Follow these three routes to ensure that you are using modifiers correctly:

• Software technologies are on hand to prompt you to select the right modifiers at the time of service.

• Do not edit your fees on the claim if you think the modifier you used is likely to reduce the amount of payment. Let the payer reduce it. Similarly, if there's likelihood of the modifier increasing the payment, increase the payment on the claim before the payer even gets his hands on it.

• You will be safe to know the payers' policies regarding the use of modifiers. Remember that rules may differ among the payers.