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 [...]