ED Coding and Reimbursement Alert

Just a quick reminder. The coding advice in this article is equally applicable to modifiers 25 and 57; the modifiers serve the same function: showing that a significant, separate E/M service preceded any other codeable procedure or service.

The only difference between modifiers 25 and 57 is the global periods attached to the procedures that follow the E/M. If the provider performs a procedure with a minor (0- or 10-day) global period, you’d append modifier 25 to the E/M code; for procedures that have a major (90-day) global period, you’d append modifier 57 to the E/M code.

Separate Dx? Not Necessarily

Sometimes, there are instances of significant and separately identifiable E/M services that don’t carry an additional diagnosis.

“A separate diagnosis code is not necessary for the use of an E/M code with modifier 25/57,” confirms Chelle Johnson, CPMA, CPC, CPCO, CPPM, CEMC, AAPC Fellow, billing/credentialing/auditing/coding coordinator at County of Stanislaus Health Services Agency in Modesto, California.

Example: A college football player suffers a broken fibula after being tackled. There was no loss of consciousness or other injuries noted, but a clear fracture is present upon examination.

It would be rare for such an ED patient not to receive an E/M visit to determine no other injuries or underlying conditions were present to inform both the fracture repair and any medication prescribed — even when the primary diagnosis is present upon examination. A patient who had a traumatic event with enough force to cause a fracture may also have other underlying injuries that should be investigated.

Typically, this encounter would be reported with an ED E/M code (likely 99284 [Emergency department visit for the evaluation and management of a patient, which requires a medically appropriate history and/or examination and moderate level of medical decision making] or 99285 [Emergency department visit for the evaluation and management of a patient, which requires a medically appropriate history and/or examination and high level of medical decision making]) with modifier 25/57 appended, depending on the global period for the fracture care code, almost certainly 90 days. You’d also report the appropriate ICD-10 code for the patient’s broken fibula along with the ED E/M code.

Also, you’d report a fracture care code with modifier 54 (Surgical care only) appended if the follow-up care was not provided in the ED setting (also with the appropriate ICD-10 code for the patient’s broken fibula).

Drill Down for These Patient Record Elements

“Modifier 25/57 can be tricky to get used to determining,” says Johnson. Remember that the documentation must fully describe the additional E/M service. “If the documentation just supports the procedure, the use of an additional E/M with modifier 25/57 would not be appropriate,” she says. If you suspect the practitioner’s work warrants use of the modifier and their documentation does not, it’s important to communicate that to them directly so they fully understand what to document.

Documentation example: For an E/M service that is significant and separately identifiable from a procedure, an auditor is going to want to see that clearly in the notes. “If you’re a provider or you’re looking for something to communicate with your provider, I suggest a paragraph to physically separate the two services,” explains Jeffrey Lehrman, DPM, FASPS, MAPWCA, CPC, CPMA, principal, Lehrman Consulting LLC, Fort Collins, Colorado. “This is my suggestion as an auditor. Begin the paragraph with something like this: ‘patient has a separate complaint today…,’ then after documenting the evaluation and management of that complaint, the last sentence should be, ‘This evaluation and management of the _________ was significant and separately identifiable from the procedure of ____________,’” he says.