ED Coding and Reimbursement Alert

Although the advent of modifier -25 (significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) for hospital billing in June 2000 promised greater reimbursement for emergency facilities, it also created confusion among ED coders. Because rules for modifier -25 in a facility setting (hospital services only) differ from those on the professional side (physician services only), the main challenge is knowing when to append it to an E/M service. CMS has released two new transmittals to clarify the issue. 
 
Transmittal A-00-40, released July 20, 2001, states that Medicare requires that modifier -25 "always be appended to the emergency department E/M codes when provided on the same day as a ... procedure." The Outpatient Code Editor (OCE) only requires modifier -25 on an E/M code when it is reported with a procedure code that has a status indicator of "S" (significant hospital procedures not subject to multiple procedure discounting) or "T" (significant services subject to multiple procedure discounting, usually surgical procedures). But the edit does not preclude appending modifier -25 to E/M codes with other procedure codes, as long as the E/M is significant and separately identifiable.
 
"The real difference in using modifier -25 for facility billing versus professional billing seems to be with diagnostic testing," says Todd Thomas, CPC, CCS-P, president of Thomas & Associates Ensuring Optimum Reimbursement for Emergency Physicians in Oklahoma City. The physician cannot bill for the test but may bill for the interpretation of the test, he says. "The modifier applies for physicians when performing services that are significant and separate from the procedure."
 
For facility billing, the diagnostic (with the exception of pathology and laboratory) and/or therapeutic procedure code ranges 10040-69990, 70010-79999 and 90281 include taking the patient's blood pressure and temperature, asking the patient how he or she feels and getting the consent form signed. The E/M service is built in to these procedures, so do not bill for it separately.
 
Sometimes, however, it is appropriate to report an E/M service in addition to the procedures provided on the same date, if the key components (history, examination and medical decision-making [MDM]) call for a higher level.
 
Modifier -25 should be appended only to facility E/M service codes within the ranges 92002-92014 (general ophthalmological services) and CPT 99201 - 99499 , and to HCPCS codes G0101 (cervical or vaginal cancer screening; pelvic and clinical breast examination) and G0175 (scheduled interdisciplinary team conference [minimum of three exclusive of patient care nursing staff] with patient present) when performed with any procedure from 10040-69990, EKGs, radiological procedures and medicine codes 90281-99xxx (exclusive of E/M services).
 
The OCE will continue to process claims for those procedure codes that are assigned to other than "S" or "T" status indicators if they are reported with an E/M code and a modifier -25.
 
For the professional side, append modifier -25 to the E/M service only if the physician performs a significantly identifiable procedure. In other words, the ED physician must perform a procedure to be reimbursed for both the E/M service and the procedure. "The determination (to apply modifier -25) is based on what the history, exam and MDM reveal," Thomas says. 

 
Much of the confusion about the separate and distinct nature of modifier -25 results from the difficulty in recognizing the separate and distinct service in the documentation. To qualify for the -25 modifier, the separate and distinct history and physical 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.
 
For example, when an ED physician examines an injury and must perform only a minor repair, it is clearly an E/M service only. But, if the ED physician evaluates a patient with an injury and determines that a laceration repair is necessary based on the history, examination and MDM, the surgical procedure is separate from the E/M service. It does not matter if the physician evaluating the patient initially or another physician (e.g., plastic surgeon or other) does the repair.
 
In a second example, a patient presents to the ED after a motor-vehicle accident (MVA) with a 1-cm forehead laceration, multiple body abrasions, headache and dizziness. The ED physician orders a head CAT scan and multiple x-rays (for the extremity abrasions). The doctor sutures the forehead laceration with a simple closure and makes the final diagnoses of open wound of forehead and multiple abrasions. A comprehensive exam and complex MDM were performed.
 
For the professional coding (the physician services only) assign ICD-9 codes 873.42 (face without mention of complication, forehead), 919.0 (abrasions of multiple sites) and E812.0 (other motor vehicle traffic accident involving collision with motor vehicle). In this case, report 99285-25 (emergency department visit ...) and 12011 (simple repair of superficial wounds ...). Modifier -25 is assigned because even though the patient presented to the ED with multiple complaints following the MVA, radiological exams were conducted, suturing was done, etc. The ED physician's suturing is a separate procedure and holds a type "S" or "T" status.

 
Using Modifier -25 for Facility Billing

 
"Append modifier -25 only if the patient needs other services that are separately identifiable," says Barbara Steiner, RN, ART, ER coding coordinator for Northeast Medical Center in Concord, N.C. "Don't append modifier -25 on the E/M if all the patient receives is a shot of penicillin." Some evaluation may be necessary beyond taking the patient's vital signs and asking how he or she feels. But just because the facility appends modifier -25 to an E/M doesn't mean the physician can.
 
For example, a patient presents to the ED with a migraine. The ED physician schedules a CAT scan of the brain (70450) and sends the patient to radiology. Although the physician bills only for the E/M service, the facility must append modifier -25 to the facility E/M code because of the radiological procedure performed.
 
CMS uses the following examples in its transmittal to illustrate a facility E/M service with modifier -25 appended:
 
1. A patient complaining of rapid heartbeat is seen in the ED. The physician performs a 12-lead ECG. The appropriate code(s) from the following ranges can be reported:
 

ED E/M codes 99281-99285 with modifier -25
 

93005 (electrocardiogram, routine ECG with at least 12 leads; tracing only, without interpretation and report)
 
2. A patient is seen in the ED after a fall. The doctor repairs lacerations sustained from the fall and takes radiological x-rays. In this case, the appropriate code(s) from the following ranges can be reported:
 

ED E/M codes 99281-99285 with modifier -25
 

12001-13160 (repair)
 

70010-79900 (radiology).

 
To code the services for the facility component in the previous MVA example, use the same ICD-9 codes, 873.42, 919.0 and E812.0. Cases of MVA/trauma generally call for a level-four or level-five E/M code. Append modifier -25 to the E/M code chosen. Also report 12011, 70496 (computed tomographic angiography, head ...), 73090-50 (radiologic examination; forearm two views; -bilateral procedure) and 73590-50 (... tibia and fibula, two views).
 
The key to using modifier -25 properly is the service provided. In the above example, if there was no forehead laceration, the professional fee would not include a laceration repair and, therefore, the E/M level would not need modifier -25. However, for the facility side, because radiological exams were performed, modifier -25 would be appended to the hospital E/M because the exams are significant, separately identifiable procedures.
 
Modifier -27 Versus Modifier -25

 
CMS released transmittal A-01-80 on June 29, 2001, further clarifying modifier -25 while introducing modifier -27 (multiple outpatient hospital evaluation and management encounters on the same date) for hospitals, effective October 2001. Now coders must distinguish between facility and professional use of modifier -25 and distinguish between modifiers -25 and -27.
 
Although CMS will accept modifier -27 for outpatient prospective payment system claims, this modifier will not replace condition code G0 (two separate and distinct visits provided on the same date of service in the same revenue center, by two different physicians). The reporting requirements for G0 have not changed. Continue to report G0 for multiple medical visits that occur on the same day in the same revenue centers.
 
Modifier -27 can be appended only to E/M service codes within ranges 92002-92014 and 99201-99499 and with G0101 and G0175. It may be appended to the second and subsequent E/M code when more than one E/M service is provided to indicate that the service is a "separate and distinct E/M encounter" from the one previously provided the same day in the same or different hospital outpatient setting, i.e., two separate visits on the same day. It will be crucial that office staff pay close attention to where patients are sent within hospitals so the accompanying paperwork and documentation can be attached for the billing personnel within the departments.
 
The AMA CPT editorial panel approved modifier -27 to delineate a hospital facility reporting when a patient receives multiple E/M services by the same or differing physicians(s) in multiple outpatient hospital settings. This new modifier was approved to assist reporting of hospital resources related to separate and distinct E/M encounters performed on the same patient and provided by the same or different physician(s) in more than one (different, multiple) outpatient hospital setting(s) (e.g., hospital emergency department, clinic) on the same date.