Advanced Search

Gastroenterology Coding Alert

Start Paper Trail Early for Modifier -25 Claims

Published on Sat Oct 09, 2004

Documentation must prove significant, separate E/M for reimbursement

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, the E/M service is often reportable 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).

Modifier -25 Use Is in Feds' Crosshairs

Improper use of modifier -25 has been on the rise in the past decade, and it's made regulators take notice. In 2003, the Department of Health and Human Services instructed its Office of the Inspector General (OIG) to start paying extra attention to modifier -25 claims in an attempt to catch people who were taking advantage of the modifier.

However, experts contend that if you do things right the first time on your modifier -25 claim, you'll have no reason to sweat the OIG and will reduce the chances of denial, regardless of carrier.

Proving Separate Service Is Priority 1

The most difficult modifier -25 issue is ensuring that the E/M service is actually separate from the other procedure, not just a component of the procedure, according to Lisa Center, CPC, of Freeman Health System in Joplin. Mo.

"Each service - the E/M and the procedure - needs to be able to stand alone [on the claim]. That is the point of the -25 modifier; to show it is a separately identifiable service," Center says.

E/M for PDT Nausea = Reportable Service

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:

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 level-two E/M service for the nausea attacks.

Since 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.

  • attach ICD-9 code 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 the nausea treatment would be considered 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. Let's look at this example, provided by Amy Walker, CPC, CCP, insurance supervisor at Gastrointestinal Associates PC in Knoxville, Tenn.

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

    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.

  • attach modifier -25 to 99204.

  • append ICD-9 code 787.1 (Heartburn) to 43235 and 99204.

  • append ICD-9 code 787.2 (Dysphagia) to 43235 and 99204.

    Modifier -25 should be appended to the E/M service because the decision about performing the EGD was not made until after the gastro evaluated the patient.

    Good Documentation Makes a Rock-Solid Claim

    Documentation can make or break a modifier -25 claim, and 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, according to Audrea Burke, CPC, of Altru Health System in Grand

    Forks, N.D. "The physician must be able to document a separate service; some coders recommend a separate paragraph discussing the separately identifiable E/M service ... or preferably a separate page," Burke says.

    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, Burke says.

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

    • Other Articles in this issue of

    Gastroenterology Coding Alert

    View All