ED Coding and Reimbursement Alert

Few days pass when professional coders who often code dozens of records in each eight-hour period aren't faced with the prospect of adding modifiers to the services emergency physicians provide. In some cases, the choice of modifiers is clear and the circumstances requiring them undeniable. At other times, however, the coding may be less than clear-cut.
 
"Modifiers have been implemented with a very clear purpose," says Carol Pohlig, BSN, RN, CPC, who works in the department of medicine at the Hospital of the University of Pennsylvania. "They identify circumstances or procedures that vary from the original code description. It alerts the payer that something unusual has taken place. Because modifiers address exceptions and not the rule, the potential for misuse or abuse is significant."
 
To ensure no misuse or abuse takes place, coders must understand the distinctions between modifiers, when they should be applied, and how best to submit modified codes to ensure greatest likelihood of payment.

Two foundational truths about modifiers increase reimbursement success, Pohlig says. "To begin with, coders must recognize that not all insurers treat modifiers the same way. Medicare, for instance, recognizes most of the modifiers that appear in the CPT manual. Medicare also relies heavily on Level II HCPCS modifiers. Other insurers recognize none of them. Still others recognize some, but not all. Coders should work closely with payer representatives to understand how that particular insurer approaches modifiers."
 
Secondly, she adds, coders must submit the claims in the most effective manner. "A lot of coders don't realize that claims containing certain modifiers should drop to paper (e.g., modifier -22, Unusual procedural services; modifier -52, Reduced services; modifier -53, Discontinued procedure). Typically these are automatically denied, with a request for more information explaining the circumstances requiring the modifier. Rather than wait for the denial and request for supporting documentation, practices are better off submitting the claim on paper with the progress notes or procedure report already attached."
 
If modified claims are denied after submission of the documentation, Pohlig advises that ED coders request peer review. "Make sure the claim is reviewed by a healthcare practitioner who practices in the same specialty and is familiar with the procedure. They are the only ones who will completely understand the circumstances and the service, thereby increasing the likelihood of ultimately getting paid."

The most problematic modifier for emergency department coders is modifier -25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service), according to Karen Benson, CCS, a coding supervisor for North Shore Medical Center in Salem, Mass. "There are two major issues that arise with the -25 modifier in my experience," she says. "Coders aren't sure when they can use it, and they may confuse which code it should be appended to."
 
Because most non-starred procedure codes include an inherent level of E/M service, it becomes difficult to distinguish an E/M that is truly significant and separately identifiable from other services provided at the same time, Benson points out. For example, a patient may come into the ED with a diagnosis of a fractured arm with an x-ray from a private physician's office. The ED physician simply applies a cast to the arm. In this case, the limited exam is included in the surgical package and not billed separately. Only the procedure code would be reported.
 
When a separate E/M service is performed, however, it is best if it is clearly documented preferably with a separate note within the patient record. "For instance, an ED physician may examine an elderly female patient who was involved in a motor vehicle accident (MVA). She suffered a broken arm (e.g., 812.21, Fracture of humerus; shaft of humerus), but also complains of a headache (e.g., 784.0, Symptoms involving head and neck; headache) and chest pain (e.g., 786.50, Chest pain, unspecified). The physician will treat the fracture, but also conduct a thorough E/M service to determine the cause of the head and chest pains." In the case of non-starred procedures like this, where the E/M service is clearly distinct and significant, the ED physician should report the procedure code (e.g., 24500, Closed treatment of humeral shaft fracture; without manipulation), as well as the appropriate level of E/M visit (99281-99285, Emergency department visit) appended with the -25 modifier.
 
Benson notes that many ED coders erroneously add the modifier to the procedure code instead of to the E/M code. "Sometimes, these coders have worked in other specialties where modifiers usually appear with the procedures. It takes some training to change this pattern so they know to add modifier -25 to the E/M service code."
 
She adds that reporting E codes also adds weight to claims where both a procedure and an E/M code are used. E codes are used along with diagnosis codes to explain the circumstances surrounding injuries and accidents. "If a claim indicates that a child was seen in the ED because of a broken arm suffered because of a fall from a window (e.g., E882, Fall from or out of building or other structure), the insurer will better understand why the physician performed an extensive E/M service along with the fracture care," Benson points out.

In addition, modifier -57 (Decision for surgery) is frequently confused with modifier -25, yet is used only under specific conditions. CPT contains language that directly affects the use of the -57 modifier with a procedure. However, modifier usage changes if the service is very closely related to the procedure.
 
In yet a third example, a patient falls on his arm and the ED physician examines it, performs an x-ray and assesses the neurovascular status of the arm. This level of service falls somewhere between the separate exam of the MVA above and the very limited exam of the patient from the private physician's office. In this case, the physician is making the decision to perform the procedure. As such he or she would appropriately charge an E/M code and append the -57 modifier to indicate that some service beyond the procedure was performed. The difference between the totally separate service, the related service and the decision to perform a procedure is very difficult to determine. Nonetheless, CPT requires that physicians and coders make these distinctions through documentation.
 
Coders should remember that Medicare does not recognize the starred procedure concept. Instead, Medicare differentiates between procedures and surgeries through the use of global periods of 0, 10 or 90 days. As a rule of thumb, many practices append the -25 modifier to any separate and identifiable E/M service for procedures with a global period of 0-10 days. For procedures with a global period of 90 days, the -57 modifier should be added to any separate and identifiable E/M service. As always, local and regional carriers differ in their application of the Medicare guidelines, and ED practices should contact their local carrier for guidance.

Other modifiers that are commonly misused are -51 (Multiple procedures) and -59 (Distinct procedural service). Modifier -51 is used when multiple services are performed and communicates that the codes submitted are not being added to the claim in error. For instance, modifier -51 should be appended when multiple CT or x-ray services are provided to the same patient on the same date of service, especially if the same CPT code is used more than once on the claim. When used in compliance with Correct Coding Initiative (CCI) rules,  the -51 modifier should prevent the rejection of the second and/or subsequent procedures as duplicates or included services. Under other clinical circumstances modifier -59 would be used. Often called the "modifier of last resort," modifier -59 is usually appended to the component code when the CCI attaches an indicator of "1" to a specific code pair, which means a modifier may be appended to bypass the edit.
 
Modifier -51 might be used, for instance, when a patient has three single-view chest x-rays on the same date of service and the coder wants to ensure that the last two codes are not rejected as duplicate submissions. Modifier -59 might be used when a four-view knee film is obtained and a fracture is diagnosed. After reduction and casting, a two-view knee series is performed. The two-view series is bundled into the four-view series by the CCI edit. However, ED coders would use -59 with the second study to ensure payment.

Most coding experts note that use of modifiers -76 and -77 is easier to understand. Modifier -76 is assigned when the same procedure is repeated by the same physician. For instance, maybe three abdominal x-rays are taken on the same patient throughout the course of the day and read by the same ED physician. Modifier -77 is similar to -76, but is assigned when a repeat procedure is conducted by another physician perhaps follow-up x-rays are interpreted when a second ED physician is on duty. In both cases, the modifier is appended to the second and subsequent occurrences of the code on the claim form.
 
The need for repeated procedures may arise, for instance, if an infant is brought in suffering from respiratory distress (e.g., 786.09, Symptoms involving respiratory system and other chest symptoms; other). It may be medically necessary to perform four or five portable single-view chest x-rays on the same day to assess how well the child's lungs are functioning. The first x-ray would be reported using 71010 (Radiologic examination, chest; single view, frontal). Subsequent x-rays would be assigned 71010-76. If another physician within the same group practice or a different professional organization read any of these x-rays, they would be coded 71010-77.

Used less frequently but often causing confusion are modifiers -22, -52 and -53, Pohlig explains. The -22 modifier is used to report additional work and effort during any given procedure, she explains. "It requires special documentation. For instance, if a procedure took 40 minutes when it typically only requires 20 minutes, the ED physician would describe the circumstances that necessitated the longer time and greater effort."
 
When using modifier -22, emergency physicians should increase the charges submitted to the insurer to adequately reflect the additional effort involved. "Don't count on the payer to automatically increase payment," Pohlig warns. "They won't understand the value of the additional service." Even so, whether the insurer will actually pay the higher rate is uncertain.
 
Modifiers -52 and -53, which allow emergency physicians to recoup partial expenses when procedures are aborted, are often confused. Modifier -52 is commonly used when the procedure performed is less than typical. For instance, a patient may present with a dog bite to the leg that is gaping open. The ED physician would place one or two simple sutures to close the skin, but would not insert the normal number of sutures for the length of the laceration.
 
Modifier -53, on the other hand, represents more extenuating circumstances when the patient's health and well-being might be affected by continuing the service. The physician may recognize that the patient is not tolerating the procedure, or a complication might arise that puts the individual's health in jeopardy.
 
"With both the modifier -52 and -53," Pohlig says, "ED physicians should not discount the charges they submit. They should submit their full charge on paper with a description of how far they progressed with the procedure. Usually, the insurer will pay a percentage, based on what part of the service was completed."
 
Note: Some coding experts strongly disagree with recommendations not to reduce charges when submitting claims appended by modifier -52 or -53. They advise coders to charge only for what was done. If only a partial procedure was accomplished, the practice should not charge for the complete service.

Pay Attention to Modifiers -26, -32, -54

Coders should also be alert to proper use of other common modifiers. For instance, if the ED physician only interprets x-rays of the ribs taken in the hospital radiology department, modifier -26 (Professional component) would be added to the appropriate procedure code (e.g., 71100, Radiologic examination, ribs, unilateral; two views). The technical component of the service would be billed by the facility.
 
Likewise, coders should be cognizant of when to append modifier -32 (Mandated services). This modifier is used when the exam or service provided is required by a third-party payer, governmental or legislative agency or regulatory requirement. For instance, modifier -32 might be required in rape or assault cases, added when the exams are being conducted at the request of a police officer, or other state or local government agency like social services.
 
Finally, ED services will routinely be modified with modifier -54 (Surgical care only) to indicate that the physician provided only the surgical procedure and that all follow-up care will be provided by another physician.