ED Coding and Reimbursement Alert

Who knew that one little modifier could do so much damage for ED coders? But put modifier -25 on your claims, and you'll have payers up in arms. Defend your modifier -25 claims right from the start and avoid those timely denials.

The easiest way to report and get paid for modifier -25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) is to clean up and clarify these claims before they go out. Here's how.

1. Append modifier -25 only to E/M services. Do not use it on any procedure codes. You should use modifier -25 with an E/M service that's performed on the same day by the same physician as a procedure in the ED, says Sandra Soerries, CPC, CPC-H, director of healthcare compliance services for Tait Advisory Services in Kansas City, Mo. Many coders understand this concept, but in the flurry of getting claims out, they accidentally append the modifier to a procedure code.

2. Do not append modifier -25 to E/M codes when the only other codes for that claim are for ancillary services, like echocardiograms (EKGs) and x-rays. Also, some carriers restrict the use of modifier -25 to an E/M coded out with a surgical service. Because there is some variation in this area among payers, please consult your local carrier for its specific policy.

3. Include separate documentation for both your E/M and procedure codes. You need to show medical necessity that justifies reporting both the E/M code and the procedure code(s). So, you must have separate documentation for both, Soerries says.

If you bundle your procedure note into the examination component of the E/M documentation or even tag it in the decision-making component, you could be losing legitimate revenue, she warns. Say a patient presents following a bicycle accident, and the ED physician does more than just walk into the room and perform a laceration repair. In addition, the patient has an abrasion on the knee and complains of abdominal pain. The physician documents an examination, which includes the knee and abdomen.

You want to include all the needed E/M documentation, including the plan to repair the laceration. Then you want separate documentation for the repair to show you have reason to report a complete E/M separately. The repair documentation can be on the same sheet, or it can be on a separate piece of paper, Soerries says. You can provide the mini-operative report of the repair that tells how the patient was prepared, what type of anesthetic was used, how many sutures were applied, and other relevant details, she says.

4. If you're still not getting paid, contact the representative for the relevant payer. Mary Dykstra, RT, CPC, billing manager at Medical Center of Stafford in the Roanoke, Va., area, has problems getting paid for claims that include modifier -25. She finally called a representative at Blue Cross Blue Shield, who told her that the patient's BCBS program does not recognize modifier -25 or E codes.

At this point, turn the problem over to your billers. When Dykstra's office billers appeal the claim, they ask for charts to justify the need to report both codes. Their denial is reversed 95 percent of the time.

It's still a lot of work for billers, so make their job easier by having all your charts and documentation in order when it's time to appeal.