ED Coding and Reimbursement Alert

In the emergency department, there are no established patients. Thats why the ED services codes (99281-99285) dont make that a distinction. And obviously, there are no planned procedures in the ED either.

The combination of these two facts should indicate to most emergency physicians that their E/M codes should almost always have the modifier -25 attached if they perform a procedure on a patient after the initial evaluation, says Todd Thomas, CPC, CCS-P, president of the Oklahoma City, OK, chapter of the American Academy of Professional Coders and principal of Thomas and Associates, an emergency medicine reimbursement consulting firm.

No one presents to the emergency department and instructs the physician to splint their broken arm, Thomas states. They come in, the doctor performs an examination and determines a course of treatment, then performs the procedure.

If that is the case, then modifier -25 (significant, separately identifiable procedure performed by the same physician on the same patient on the same day) should be attached to the E/M code. This modifier enables the physician to get paid for both the E/M service and the procedure. If the modifier is not attached, third-party payers often only reimburse one of the codes, usually whichever is less expensive.

However, the modifier is often omitted by ED physicians who dont realize they should be using it, and coders often dont apply it because they dont have the necessary documentation to indicate it should be added.

Ive had several docs say to me that they dont use the modifier if they know just by looking at the patient what is wrong with them, Thomas says. I try to convince them that they performed an evaluation and, even if it is a brief evaluation, they should get paid for that service in addition to [getting paid for] performing the procedure.

Use Modifier -25 on Critical Care Codes

Use of modifier -25 is particularly lacking when critical care E/M codes (99291-99292) are billed, notes Jackie Davis, president and CEO of Term Billing, Inc. an emergency physician group billing company based in Arlington, TX.

Lifesaving procedures such as CPR and intubation often accompany critical care services, she says. But, if these procedures are billed along with critical care codes, often the procedures are not paid for because the modifier -25 is not attached to the E/M code.

Because critical care is time-based and not like the other E/M level codes, many coders dont think the modifiers should be applied, she says. But, Medicare views critical care codes as E/M codes. So coders should always put the modifier on the critical care code to get reimbursed for the procedures.

Note: Modifiers are not always recognized by all third-party payers. Although most larger payers follow Medicare, you should check with the health plans you contract with for their specific requirements.

Dont Use Modifier on All E/M Codes

Although for emergency physicians, modifier -25 will apply to most evaluation services, this does not mean that EDs can make it a blanket rule.

The main thing is, you have to be careful and not just tack it on every E/M level, Davis advises. I have seen cases where the coder saw a procedure, decided that there must have been an E/M service to go with it, and added the E/M code with the modifier (without the documentation to back it up).

The procedure may be a global surgical procedure and the E/M service would be bundled, she adds. It really does have to be a significant, separately identifiable service. If you have a global surgery laceration repair and the physician didnt do anything else, then it is not appropriate to use an E/M code with it.

Although most ED evaluation and management services would warrant use of the -25 modifier if a procedure is performed, Davis says she feels that if a patient presents with a very minor injury that the doctor treats immediately, then a separate E/M code should not be billed.

If a patient comes in with a nosebleed and all you do is control the nasal hemorrhage, then I would not bill an
E/M, she says. However, if the patient comes in with a nosebleed and you control the bleeding and then evaluate them for hypertension, that is different.

Diagnosis Codes Can be the Same

Although it is commonly thought, by both coders and payers, that E/M codes with a -25 modifier must have a separate diagnosis code than the one linked to the procedure, this is not the case. There are a few instances where that is true, says Davis. However, in many cases there wont be a separate diagnosis.

For example, a child comes to the ED after falling from a swing and hitting his head. The emergency physician repairs a minor scalp laceration (12001*), then orders an x-ray to check for other injuries. These would probably have the same diagnosis code (873.0, wound, open, scalp, uncomplicated) if no other injury were found,
says Davis.

Dont Confuse -25 with -57

Although not a common problem in emergency departments, Davis says it is important to note that physicians should not apply the -25 modifier to an E/M code for a service that resulted in a decision to perform surgery.

You dont see it a lot in the ED, but every once in a while I will see a -25 when it should be a -57. Modifier -57 should be used to indicate that the E/M service resulted in a decision to perform surgery, she adds.

There has been some controversy about which modifier to use when billing an E/M service and a starred surgical procedure, Thomas adds. According to CPT, starred procedures are surgical codes that include only the procedure and not the pre- and postoperative services. However, CPT and Medicare guidelines differ greatly when it comes to coding for starred procedures, Thomas notes.

Many ED experts advise using the -25 modifier on the E/M code when a starred procedure is also billed, and using the -57 when the E/M accompanies non-starred procedures. In most ED situations, the -25 modifier would be most appropriate, but depending on the procedure, Medicare guidelines may advise otherwise.

Note: In our next issue, ECA will feature an
in-depth article solely devoted to coding and billing for starred surgical procedures.