Gastroenterology Coding Alert

You're familiar with the practice of appending modifier 25 when you report a significant and separately identifiable E/M service your physician provides on the same day as a procedure. But if your physician performs anal procedures, you should be aware of two other E/M modifiers to call on under certain circumstances.

When your physician performs a significant and separately identifiable E/M service that falls within a procedure's 90-day global period -- a major procedure -- modifier 25 is not appropriate. You'll need to report modifier 24 or 57. Very few codes a gastroenterologist's office reports have 90-day global periods, so this won't be something you see every day. But you should understand it when the occasion arises or risk losing payment.

Sometimes, a physician examines a patient within the 90-day global period of a major procedure, but for a different problem.

For instance, the physician operated on the patient's anus. A month later, she sees the patient for a stomach problem. That might be when you call on modifier 24 (Unrelated evaluation and management service by the same physician during a postoperative period).

When you report modifier 24, the E/M service must meet these criteria:

• The E/M service occurs during the postoperative period of another procedure.

• The current E/M service is unrelated to the previous procedure.

• The same physician (or tax ID or same group and specialty) who performed the previous procedure provides the E/M.

Example: The new-for-2009 code, 46930 (Destruction of internal hemorrhoid[s] by thermal energy [e.g., infrared coagulation, cautery, radiofrequency]), carries a 90-day global period. Let's say your physician performs 46930 on a non-Medicare patient. Two weeks later, the patient returns to the office with anal pain. The physician performs an expanded, problem-focused history and examination with straightforward decision making, and determines the patient has developed an abscess.

In this case, you'd report 99212 (Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: a problem focused history; a problem focused examination; straightforward medical decision making ...) with modifier 24 appended.

Don't miss: If the physician provides an E/M service during the global period of an unrelated procedure, you may report the appropriate E/M service code appended with modifier 24.

"Although some complications might truly be said to be related to the surgery, like an instrument left in the surgical site or failure to achieve hemostasis before closing, most post-op complications are more closely related to issues such as the patient's general health, compliance with postoperative care instructions, and exposure to infectious organisms," says Marcella Bucknam, CPC, CCS-P, CPC-H, HIM program coordinator at Clarkson College in Omaha, Neb. "For this reason, I use modifier 24 to describe E/M services for postop complications in non-Medicare patients."

Medicare applies a different standard: Medicare payers always treat postoperative infections as related to (and therefore, included in the global surgical package of) the initial surgery -- unless your gastroenterologist must return the patient to the operating room to deal with an infection.

Occasionally, a physician wants to rush a patient into the operating room as a result of an exam. When your physician decides to perform a minor procedure as a result of an E/M service, you append modifier 25. When it's a major procedure the doctor performs the same or next day, you call on modifier 57 (Decision for surgery).

You should append modifier 57 to an E/M service that occurs on the same day, or on the day before, a major surgical procedure, and which results in the physician's decision to perform the surgery, advises Linda Parks, MA, CPC, CMC, CMSCS, an independent coding consultant in Atlanta. CMS guidelines identify a major surgical procedure as any procedure with a 90-day global period. Note that the global period for a major surgical procedure begins one day prior to the procedure itself.

Example: Your physician sees an established patient who complains of pain during bowel movements. The doctor performs an expanded, problem-focused history and examination with straightforward decision making. Your gastroenterologist decides to scrape an inflamed area in the the patient's anus -- a cryptectomy, which is a procedure that carries a 90-day global period.

For this scenario, you'd code 99212-57 (Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: a problem focused history; a problem focused examination; straightforward medical decision making ...) and 46210 (Cryptectomy; single).

Direct from the source: The Medicare Claims Processing Manual, Chapter 12, Section 30.6.6.C, instructs carriers to "pay for an evaluation and management service on the day of or on the day before a procedure with a 90-day global surgical period if the physician uses CPT modifier 57 to indicate that the service resulted in the decision to perform the procedure."

Don't look for a loophole: Scheduling pre-op services two or more days before surgery will not necessarily make the services payable. Insurers may consider such services to be screening exams unless there is some specific indication, such as hypertension or diabetes. The documentation for these visits must substantiate medical necessity and not just a routine requirement of the physician or the hospital.

To properly append modifier 57, remember: The E/M service must be related to the procedure that follows; and the same physician (or tax ID) must provide the E/M service and the surgical procedure.