ED Coding and Reimbursement Alert

By Caral Edelberg, CPC, CCS-P
President, Medical Management Resources Inc.


Emergency department (ED) coders confusion about the proper use of modifier -25 demonstrates the need for the Health Care Financing Administration (HCFA) to release its promised guidance on accurate application of this critically important modifier.

In the interim, a review of the past information provided by the American Medical Association (AMA) and used by professional component coders, as well as guidance offered by HCFA through the APC implementation process, may help those faced with coding for outpatient services muddle through the modifier process. With implementation of APCs, the HCFA edits will deny payment for an evaluation and management (E/M) code billed in addition to a procedure without the -25 modifier appended to the E/M level.

Modifier -25 is required for separate and significant E/M services provided at the same visit during which a procedure is performed. It is necessary to differentiate the separate and distinct E/M service, now considered the nursing/facility assessment level under APCs. Under Medicare professional coding guidelines adopted for use under APCs, payments for procedures include all related pre- and postoperative services.

This would mean that the preoperative history of the mechanism of injury and the examination of the site as well as the follow-up care would be bundled into the procedure descriptor and payment, although some might disagree because most preoperative services are performed after the injury has been examined and diagnosed. By following this theory, all E/M levels used to diagnose an injury that requires surgical intervention would be billed separately.

But appending modifier -25 to all E/M services billed with a procedure, including those that are not clearly significant and separately identifiable, might be expected to result in Medicare auditing the provider.

In emergency department and clinic settings, the physician is often managing an injury or injuries incidental to more significant problems. In essence, the injury requiring surgery is not the only problem the physician is managing.

For example, patients receive multiple injuries in vehicular accidents and falls that necessitate examination of multiple organs and body areas to identify other injuries. Or in the case of injuries caused by medical complications, the physicians history must identify potential sources of the problem(s) such as neurological problems and/or adverse reaction to medications.

In these situations, the physician is performing a history and physical that extends past the area of injury and can be justified as medically necessary, a significant component of establishing the need for the separate and distinct E/M service.

To date, the term significant, separately identifiable has not been objectively defined. But according to the November 1998 issue of AMAs CPT Assistant, modifier -25 is to be used to indicate that on the day a procedure or service identified by a CPT code is performed, the patients condition requires a significant, separately identifiable E/M service. This service is above and beyond the other service provided, or beyond the usual preoperative and postoperative care associated with the procedure performed.

This circumstance is reported by appending modifier
-25 to the E/M level of service reported. For the clinic setting, for example, modifier -25 should be added to the office/outpatient code to indicate that a significant, separately identifiable E/M service was provided by the same physician on the same day as the preventive medicine service.

The appropriate preventive medicine service is additionally reported. An insignificant or trivial problem/abnormality encountered while performing the preventive medicine E/M service that does not require additional work and the performance of the key components of a problem-oriented E/M service should not be reported.

Much of the confusion about determining the separate and distinct nature of modifier -25 results from the difficulty a coder may have in recognizing how the separate and distinct service is identified in the documentation.

Over the past several years, and as a direct result of the HCFA/AMA documentation guidelines and the demands these guidelines have placed on physicians to clearly itemize the documentation of their services, it is common to find history and examination extending outside the area of injury with no clear medical justification as to why an extended history and physical (H&P) was performed.

To qualify for the -25 modifier, the separate and distinct H&P must be medically necessary. Therefore, the coder must determine from the documentation of the chief complaint and history of present illness whether the physician had to consider additional problems that justify the additional level of service.

Coders should never attempt to second-guess the physician. But for those minor injuries where the evaluation and management service scores higher than problem-focused or expanded problem-focused, the coder must consider the medical necessity for the expanded examination to protect the physician from possible future audit. (Under hospital APCs, HCFA clearly has stated that use of the -25 modifier is planned for focused audits, and the Office of the Inspector General has continuously referenced it in annual work plans.)

In summary, before assigning the -25 modifier to the E/M level when a procedure is to be coded, consider the following:

1. Is there an additional injury or underlying medical problem identified in the chief complaint and/or history of present illness?

2. Does the medical decision-making element of the evaluation and management indicate more than low complexity (i.e., simple, uncomplicated and minor single-system injury without complications or other illness, injury or problem regardless of the level of history and physical examination documented)?

3. Do you realize that you dont need a separate diagnosis for the E/M service coded in addition to the procedure?

4. Have you developed an interim definition of significant, separately identifiable to be followed consistently and uniformly by all coders in your department?

5. Are you performing audits when the -25 modifier is applied to ensure that it is being used correctly?