Gastroenterology Coding Alert

 Watch out: Payer scrutiny is on the rise

 A recent CMS memo clarifies modifier 25 use, but the attention could send up a red flag to payers. Our experts offer valuable tips to help report claims without a glitch.

1. Document for Both Services

When submitting an E/M claim with modifier 25 (Significant, separately identifiable E/M service by the same physician on the same day of the procedure or other service) on the same day as another service or procedure, the physician must -appropriately and sufficiently- document medical necessity for both the E/M service and the other service or procedure, according to CMS Transmittal 954, issued May 19.
 
Important: CMS now stresses that you don't need to submit this documentation with the claim, but it must be available upon request.
 
Although the transmittal does not constitute a change in policy, you might safely guess that payers will more closely scrutinize modifier 25 claims, says Lisa Center, CPC, coder with Mount Carmel Regional Medical Center in Pittsburg, Kan.

2. Service Must Go Above and Beyond

If you can't show that the E/M service a physician provides exceeds the -inherent- E/M component of any other services or procedures he performs on the same date, you shouldn't be reporting the E/M service separately -- either with or without modifier 25.
 
Transmittal 954 (Medlearn Matters MM5025, Change Request 5025) adds the word -usual- to the instructions for applying modifier 25. The guidelines now specify that you should apply modifier 25 for -a significant, separately identifiable E/M service that is above and beyond the usual pre- and post-operative work for the service.-
 
The addition is just meant to emphasize that any extra E/M service must be -above and beyond- the typical pre-op or post-op work, says Quinten Buechner, MS, MDiv, ACS-FP/GI/PEDS, CPC, with ProActive Consultants in Cumberland, Wis.
 
Bottom line: If your doctor already plans a procedure and does a pre-op history and physical (H&P) examina-tion, don't bill for a separate E/M. But if the physician doesn't know whether the patient will need a procedure and must rule out other options, you can bill for the E/M, Center says.
 
Example: -Your gastroenterologist sees a patient in the morning for a follow-up on the reflux symptoms the doctor has been treating,- says Dianne Wilkinson, compliance officer and quality manager with MedSouth Healthcare in Dyersburg, Tenn. Later that afternoon, the same patient calls with complaints of significant rectal bleeding, completely unrelated to the earlier visit. The doctor tells the patient to go to the emergency department and treats him there.
 
-Even though this is a case of one physician billing two E/M services on the same day (normally not done), you can bill for the E/M with modifier 25 on the ED visit (99281-99285) because it was unrelated to the first visit,- Wilkinson says.

3. You Don't Need a Separate Diagnosis
 
Transmittal 954 also reminds you (and Medicare carriers) that you don't need a separate diagnosis for the same-day E/M service and other service or procedure. As long as the services are distinct and the separate E/M service is significant, you may, where warranted, link both to an identical diagnosis.
 
This statement closely mimics CPT rules, which state, -The E/M service may be prompted by the symptom or condition for which the procedure and/or service was provided. As such, different diagnoses are not required for reporting of the E/M services on the same date- [emphasis added], says Barbara J. Cobuzzi, MBA, CPC, CPC-H, CPC-P, CHBME, president of CRN Healthcare Solutions, a coding and reimbursement consulting firm in Tinton Falls, N.J.
 
Although this is a long-standing CPT rule, CMS payers on occasion will still deny a separate E/M with the same diagnosis, claiming that the E/M is not -distinct.- Now you can show these payers that Medicare guidelines specifically state, -Different diagnoses are not required for reporting the E/M service on the same date as the procedure or other service ...-
 
Example: A new consult patient arrives with a complaint of intense heartburn and abdominal pain. The gastroenterologist takes a complete history and performs an extensive exam. She then performs diagnostic endoscopy to check for reflux disease.
 
In this case, you should report the endoscopy (43200, Esophagoscopy, rigid or flexible; diagnostic, with or without collection of specimen[s] by brushing or washing [separate procedure]). Separate documentation will also support a level-three outpatient consult (99243), which you should append with modifier 25.
 
You should link the signs and symptoms that prompted the exam (787.1, Heartburn; and 789.00, Abdominal pain; unspecified site) to the E/M code. You can link the same signs-and-symptoms diagnoses to the endoscopy. Or if the doctor finds verifiable evidence of reflux disease (530.xx), you can report that diagnosis as primary with the signs and symptoms as secondary for the endoscopy.