Gastroenterology Coding Alert

If you don't use modifier -25 correctly, you could face a long appeal process, refusal of payment, or worse, an audit.
 
Although its definition makes use of less than 200 words in the CPT book, questions and concerns surrounding modifier -25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) could fill a phone book. When to use it and how to use it properly are ever-present challenges to coders. To use it wrong could mean a long appeal process or lack of payment. Modifier -25 is as controversial and confusing as ever.
 
"The most difficult issue surrounding modifier -25 is ensuring that the E/M service is truly separate and significant from other procedures performed on the same service date," says Cindy C. Parman, CPC, CPC-H, RCC, co-founder of Coding Strategies Inc., in Dallas, Ga. "Documentation must clearly support the surgical procedure and the patient evaluation as separate services, and the medical necessity for a separate visit must be clearly stated."

Follow This Lead

This scenario exemplifies the correct use of modifier -25 (pay attention, there will be a quiz):
 
A primary-care provider asks a gastroenterologist to consult on a patient with abdominal pain, cramps, and bloody diarrhea. The patient undergoes a flexible sigmoidoscopy and biopsy after in-office preparation. Report the flexible sigmoidoscopy and the consultation in this instance.
 
You should code the sigmoidoscopy 45331 (Sigmoidoscopy, flexible; with biopsy, single or multiple). For the outpatient consultation, report 99241-99245 (Office consultation for a new or established patient ...). Append modifier -25 to the consultation code because the physician performed the procedure and the consultation on the same day.

Don't Confuse -25 With Other Modifiers

One reason the use of modifier -25 is such a hot-button issue is its similarity to other modifiers in certain situations, most notably modifier -57 (Decision for surgery). "The confusion often lies in reporting the modifier with an E/M code on the same day as a major procedure," says Lisa Clifford, CPC, of Clifford Medical Billing Specialties in Naples, Fla. "When -25 and -57 get mixed up, it quite often has to do with whether it's a major global procedure or a minor procedure." But neither CPT nor CMS has specific guidelines delineating whether modifier -57 can be used with minor procedures, major procedures, or both.
 
By using modifiers -57 or -25, a gastroenterologist can be reimbursed for an office visit that is connected in some way to a procedure. Under global surgery rules, if you bill an office visit for a patient on a certain date of service that results in a decision to perform surgery, and that surgery is done within 24 hours of the office visit, you cannot be paid for the office visit. Modifiers -25 and -57 make an exception to those rules, enabling you to receive payment.
 
Many coders think that modifier -25 is for minor procedures and that modifier -57 is for major procedures. But Medicare says to use modifier -25 for procedures with a 0- to 10-day global period, and modifier -57 for procedures with a 90-day global period.
 
However, CPT does not mention global periods. The "90 days" or "0 to 10 days" requirements are just for Medicare. A blanket statement such as "modifier -57 is only for 90-day globals" can be misleading. The coder must know how individual payers interpret the -25 and  -57 modifiers.
 
In gastroenterology offices, coders can rarely call on modifier -57, so be careful when considering whether to use it. With the exception of certain hemorrhoid procedures, very few gastroenterological procedures can be coded with modifier -57.
 
Carriers vary on the acceptable uses of modifier -25, so coders would be well-served to keep up-to-date on relevant exceptions. Medicare (and many private carriers and HMOs) usually accept modifier -25 when:
 1.  there are two co-existing unrelated and separate problems, one evaluated by an E/M service and the other evaluated or treated by a minor surgical procedure
 2. one problem, finding or complaint prompts both an E/M service and a minor surgical procedure
 3. counseling and coordination of care occur on the same day, usually after and in association with a minor surgical procedure.

Careful, the Feds Are Watching

As if modifier -25 didn't present enough challenges on its own, coders have recently had to learn to deal with generalized payer suspicion as well.
 
If there ever were a good year to misuse modifier -25, 2003 would not be the one. Earlier this year, the Department of Health and Human Services instructed its Office of the Inspector General (OIG) to assess the "adequacy of controls to identify physicians with aberrant coding patterns, specifically coding disproportionately high volumes of high-level evaluation and management codes that result in greater Medicare reimbursement."
 
In other words, doctor's offices misusing modifier -25 and similar codes are in the crosshairs of OIG investigators until New Year's Eve. Using the modifier the right way will not only keep the OIG at bay but also boost your chances of getting paid.
 
Clifford says she has noticed more scrutiny paid to claims using modifier -25 lately.
 
"I can see why they're doing it," Clifford says of the OIG crackdown. "The problem is many [doctors' offices] are interpreting modifier -25 too loosely."
 
In order to avoid the red tape of appeals and the eye of the OIG, Clifford is ever vigilant on correct use of modifier -25 - for herself and her colleagues. "I preach to my doctors consistently," Clifford says. "I always ask them: 'What did you see the patient for today?' " If it's not separately identifiable from another procedure performed on the same day, Clifford quashes any thought of using modifier -25.

Test Yourself

For a checkup on how well you know modifier -25, consider this scenario and figure out how you would code it. Good luck!
 
Scenario: During a scheduled endoscopy with a single biopsy, the patient reports nausea with vomiting unrelated to the procedure, requiring a GI workup in addition to what would normally be done with an endoscopy.
 
To code this scenario, report the endoscopy with biopsy code 43202 and append modifier -25 when billing the GI workup. Another patient-care issue arose during a scheduled treatment in the example, meaning it was a "significant, separately identifiable E/M service."

CORRECTION TO ABOVE ARTICLE:

The correct code for a flexible sigmoidoscopy is 45331 (Sigmoidoscopy, flexible; with biopsy, single or multiple).