EM Coding Alert

Question: If the physician performs a colonoscopy (45380) on the same day as an initial hospital visit (99221), do we need to append modifier 25 to the 99221?

Colorado Subscriber

Answer: The full descriptors for the codes you mention are as follows:

• 45380 (Colonoscopy, flexible; with biopsy, single or multiple)
• 99221 (Initial hospital care, per day, for the evaluation and management of a patient, which requires these 3 key components: s detailed or comprehensive history; a detailed or comprehensive examination; andmedical decision making that is straightforward or of low complexity ...).

According to the Correct Coding Initiative (CCI) Edits, 99221 is a column 2 code for 45380, so you should not normally report the codes together. However, since the edits have a modifier indicator of 1, you can append a modifier to 99221 to override this edit.

Several possible modifier options are available, including modifier 25 (Significant, separately identifiable evaluation and management service by the same physician or other qualified health care professional on the same day of the procedure or other service). You will need to look at the documentation to see what's most suitable.

Remember: The documentation and clinical circumstances must always support your decision to use the modifier. Examples include separate sites or sessions for the services. Never append a modifier just to bypass the edit.