Gastroenterology Coding Alert

Decision to do minor surgery made after an eval qualifies modifier 25Did you know that when your gastroenterologist performs an EGD with biopsy, and performs a separate evaluation and management (E/M) service on the same patient on the same date, you may often report the E/M as a stand-alone service using modifier 25?But be warned: If you don't use the modifier correctly, you could open your office to a long appeals process, a denial -- or even an audit. Read on for some practical coding information regarding modifier 25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service).Proving Separate Service Is Priority 1The most difficult modifier 25 issue is ensuring the E/M service is actually separate from the other procedure, and not just a component of the procedure, according to Lisa Center, CPC, of Freeman Health System in Joplin. Mo."Sometimes you have to look at the documentation to see if it really qualifies for a modifier 25," says Babita Singh, CPC, coding compliance auditor for Sutter Gould Medical Foundation in Modesto, Calif.Best advice: "Ask yourself, is it really separate from the E/M or did the provider merely go beyond the service provided," Singh said.Keep in mind: You cannot bill an E/M service for the standard pre-procedure history and physical needed prior to a moderate conscious sedation administration.E/M for PDT Nausea = Reportable Service"Usually you'll apply a modifier 25 when the provider does a procedure during the visit that is separate from the E/M?" Singh says.Take a look at this scenario, in which you can report both a procedure code and an E/M code with the help of modifier 25.Scenario: A patient now undergoing photodynamic therapy (PDT) for treatment of thoracic cancer reports to the office for an upper gastrointestinal endoscopy (EGD) with biopsy. When checking in at the front desk, the patient also reveals that he has had severe nausea attacks and vomiting since the PDT began a month ago. The gastroenterologist performs the EGD with biopsy, and then provides a level-two E/M service for the nausea attacks.Because the time and expertise the doctor expended on the patient's nausea were totally separate from the biopsy, you can report the E/M service and the procedure. On your claim, you should:
 • report 43239 (Upper gastrointestinal endoscopy including esophagus, stomach, and either the duodenum and/or jejunum as appropriate; with biopsy, single or multiple) for the biopsy
 • attach ICD-9 code 150.1 (Malignant neoplasm of esophagus; thoracic esophagus) to 43239
 • report 99212 (Office or other outpatient visit for the evaluation and management of an established patient, which requires at least two of these three key components: a problem-focused history; a problem-focused examination; straightforward [...]