ED Coding and Reimbursement Alert

In the February issue of ECA (pages 9-10), we covered billing for an evaluation and management (E/M) service and a procedure performed on the same day by using the -25 modifier (significant, separately identifiable service performed by the same physician on the same day).

In most cases, if a patient presents to the emergency department with a complaint, the ED physician performs an evaluation, determines the course of treatment, and then treats the patient for the complaint.

For example, a child falls from a playground jungle- gym and is brought to the emergency department, where the physician on duty examines the child for injuries, orders specific x-rays, establishes a diagnosis of a simple laceration and contusion of the forehead.

In that situation, most coders know that the appropriate level E/M code (99281-99285) should be billed for the head to toe evaluation of the child, in addition to the code or codes for any procedures performed. In this case, the procedure would be laceration repair (12011*-simple repair of superficial wounds of the face, ears, eyelids, nose, lips or mucous membranes, 2.5 cm or less). The modifier -25 should be attached to the E/M code to ensure payment.

However, determining the correct use of the modifier -25 is complicated when starred surgical procedures are performed.

Starred Procedures in CPT

Surgical procedure codes are interpreted differently in CPT and the Medicare fee schedule.

CPT defines surgical procedures as starred
(without definite pre- and postoperative services) and non-starred procedures (with a definite set of pre-and postoperative services).

Non-starred procedures normally include a set number of days included in a global surgical period. Any treatment related to that procedure that is performed within its global period of dayswhich can range from zero to seven days for simple procedures and up to 90 days for complicated onesis deemed to be included in the code for that procedure. Most E/M services related to the surgery would be included in the procedure code.

But, starred procedure codes, which have no definite follow-up period assigned to them, include the procedure only and not any pre- or postoperative services.

CPT 1999 states: Certain relatively small surgical services involve a readily identifiable surgical procedure but include variable preoperative and postoperative services (e.g., incision and drainage of an abscess, injection of a tendon sheath, manipulation of a joint under anesthesia, dilation of the urethra). Because of the indefinite pre- and postoperative services, the usual package concept for surgical services cannot be applied. Such procedures are identified by a star (*) after the procedure number.

If a starred procedure is performed in the ED, an evaluation and management service could be billed based on the documented medical decision-making to account for the variable pre- and postoperative service, says Barbara Cole, RN, BSN, CPC, vice president of pre-billing operations for Reimbursement Technologies, Inc., in Blue Bell, PA.

So, as in the previous example with laceration repair, an E/M code could be billed in addition to the starred surgical code, even if no significantly separate service had been performed.

For example, if a patient presents to the ED with a minor injury, say a small, swollen abscess on the finger, then the physician would perform a cursory examination of the finger before repairing it, Cole says. This service would not be considered significant and separate from the incision and drainage of the abscess (26010*).
But, according to CPT guidelines, an E/M level could still be billed in addition to a starred code because the procedure code does not include pre- and postoperative services, but only the procedure itself.

CPT allows you to bill an E/M, and it doesnt necessarily have to be a significant and separate service because they dont have clear-cut guidelines for what pre- and postoperative services are for these procedures, Cole states. If a starred surgical procedure is performed in the ED, an E/M service could also be billed based on the documentation and medical decision-making to account
for the variable pre- and postoperative services provided.

Editors note: CPT has recently clarified that 99025 (initial [new patient] visit when a starred surgical procedure is the major service at the vist) is not relevant in the ED setting, which does not differentiate new and established patients, initial or subsequent visits.

Medicare Caveat

However, these rules are not applicable when billing Medicare, says Cole. Medicare divides surgical procedures into only major and minor procedures. And, both sets of procedures include the pre- and postoperative services in the procedure code. Medicare will not pay for a minor surgical procedure and an E/M service on the same day unless the service is significant and separately identifiable.

A separately identifiable E/M could be billed, with a -25 modifier attached, she notes.

For example, if a patient presented with undetermined injuries, was examined by the ED physician, and then a starred procedure was performed, the coder would still be able to bill an E/M code with a -25 modifier for Medicare.

Take the case of a person who fell from a ladder and hit his head, causing a laceration, she illustrates. When the patient comes in, there is a question of the potential for head injury and probably a need for neurological assessment to rule out any significant trauma besides the laceration.
The ED physicians examination of the patient to rule out any other injury would qualify as a separately identifiable E/M service, she says.

The physician could bill a 12011* for the laceration repair, plus an emergency service E/M code (99281-99285) for the examination to rule out other injury.

But, if the laceration repair, a minor procedure, was the only service performed, then any related E/M services would be considered a preoperative service by Medicare and included in the procedure code, she explains.

Use of the -25 Modifier vs. the -57 Modifier

When billing for surgical procedures performed in the ED, there is also some confusion about whether to bill the E/M service with a modifier -25 or a -57 modifier.

Modifier -57 is used to indicate that an E/M service resulted in a decision to perform surgery. So, many coders have logically concluded that if a patient presented with a complaint, and the physician, after evaluating the injuries, performed a surgical procedure, then the -57 modifier should be used. That is not always the case.

Again, use of these modifiers is payer specific, Cole emphasizes. For Medicare in particular, in most cases they dont want to see a -25 modifier with a global surgery procedure.

The rationale for this is that the -57 modifier should be used when an E/M service results in a decision to perform a major surgical procedure. According to Medicare guidelines, a major procedure is one with a global period of at least 90 days, she adds.

The usual rule of thumb for billing a separate E/M service and a surgical procedure is to use the -25 modifier when starred procedures are performed and the -57 when non-starred procedures are performed, she says.

However, there are exceptions.

Intubation (31500) is a non-starred surgical procedure, but due to its nature, does not have any follow-up days in its global package, Cole says. It takes a -25 and not a -57.

Coders should use the above rule of thumb, but only for Medicare when the surgical procedure has a specified global period.