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 [...]