Gastroenterology Coding Alert

Decision to do minor surgery made after an eval qualifies modifier 25

Did 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 1

The 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 medical decision-making) for the E/M service with modifier 25 appended
 • attach 787.0X (Nausea and vomiting) to 99212.

Remember: The reason you can report a separate E/M service is that the nausea was caused by something other than the EGD with biopsy. If the gastroenterologist performed the EGD and then treated the patient for nausea related to the EGD, you could not report the E/M separately because payers consider the nausea treatment bundled into 43239.

Separate Symptoms May Mean Separate E/M

You may also be able to report a procedure code and E/M service with modifier 25 when the gastroenterologist treats a patient with multiple symptoms.

Coding example: A new patient presents with complaints of heartburn and difficulty swallowing. Because of the symptoms the patient exhibits, the physician decides a complete evaluation is necessary to devise a treatment plan. After providing a level-four E/M service, the gastroenterologist decides to perform a diagnostic endoscopy on the same day as the visit.

In other words: The gastroenterologist decided to perform the procedure after he provided the E/M service.

On the claim, you should:
 • report 43235 (Upper gastrointestinal endoscopy including esophagus, stomach, and either the duodenum and/or jejunum as appropriate; diagnostic, with or without collection of specimen[s] by brushing or washing [separate procedure]) for the endoscopy
 • report 99204 (Office or other outpatient visit for the evaluation and management of a new patient, which requires these three key components: a comprehensive history; a comprehensive examination; and medical decision-making of moderate complexity) for the E/M service with modifier 25 appended
 • link 787.1 (Heartburn) to 43235 and 99204
 • link 787.2 (Dysphagia) to 43235 and 99204.

Get this straight: You should append modifier 25 to the E/M service because the physician didn't make the decision about performing the EGD until after he evaluated the patient. Other minor surgical procedures commonly performed on the same day as an E/M service include anoscopies, flexible sigmoidoscopies and hemorrhoid treatment procedures.

Good Documentation Makes a Rock-Solid Claim

Documentation can make or break a modifier 25 claim, Singh warns. Expert coders are well aware of the paper trail you should attach to any claim with modifier 25. These coders also know they must communicate with their doctors so the coding department gets all the modifier 25 documentation it needs.

Solution: Many coders ask for a separate note explaining the reason for the E/M service. Documentation proving a distinct reason for the E/M visit is vital to the success of any modifier 25 claim. The physician must be able to document a separate service. In other words, the E/M note must stand on its own and contain all the elements of history, physical exam and medical decision making needed to select the level of service you will code.

Some coders recommend a separate paragraph in the procedure notes discussing the separately identifiable E/M service or -- even better -- a separate page dedicated exclusively to the E/M service.

Modifier 25 Is Not for Major Surgery

One time you should not use modifier 25 is when a surgeon performs a separate E/M service and then decides to perform a major surgery on the basis of that evaluation. When the physician decides on surgery in the course of an E/M service, use modifier 57 (Decision for surgery) on your claim. 

Rule: Apply modifier 25 to evaluation and management codes only.