General Surgery Coding Alert

Payers may make it harder to use this modifier.

The good news is that Cigna once again delayed implementing a policy that would have made it more difficult to bill for a minor surgery on the same day as a significant, separately identifiable E/M service.

The bad news is that the policy is delayed, not cancelled, and other payers may want to follow suit.

Background: Cigna intended to implement the policy in August 2022, but delayed the update until May 2023.The payer has now delayed again, stating that it will continue to review for implementation.

Help is here: Read on for our experts’ rundown of when and how to document and use modifier 25 (Significant, separately identifiable E/M service by the same physician on the same day of the procedure or other service) to ensure clean claims and accurate payment for your surgeons.

Know When and How to Use 25

Regardless of payer, E/M services performed during appointments for minor office procedures are not separately billable under normal circumstances. In fact, the decision for minor surgery is included in the surgical package, so deciding to perform a minor procedure during an office visit does not, by itself, warrant a separate E/M service.

Exception: When your surgeon performs and documents a significant, separately identifiable E/M service on the same date as a minor procedure, you can legitimately append modifier 25 to the E/M code and expect payment for both services. In most cases, you don’t need to submit documentation with the claim unless the payer specifically requests it.

For example: A 72-year-old established patient presents for suturing a 8 cm laceration of his left forearm. The patient states that he fell the preceding day and used butterfly bandages to close the wound without presenting for medical care. He’s presenting today because he has been unable to control bleeding and maintain wound adhesion. The surgeon reviews the patient’s tetanus vaccination status, and noting a bruise on the forehead, asks the patient about headache and nausea and performs a brief neurological exam including strength, reflexes, balance, vision, sensation, and mental status, and reports the diagnosis as S51.812A (Laceration without foreign body of left forearm, initial encounter). The surgeon then performs 12004 (Simple repair of superficial wounds of scalp, neck, axillae, external genitalia, trunk and/or extremities (including hands and feet); 7.6 cm to 12.5 cm), giving the patient instructions to keep the bandage clean and dry and return in 10 days.

Separate: By documenting the patient’s vaccination status and the brief neuro exam for possible concussion from the fall, the surgeon can legitimately report the service using the appropriate code such as 99213 (Office or other outpatient visit for the evaluation and management of an established patient, which requires a medically appropriate history and/or examination and low level of medical decision making. When using time for code selection, 20-29 minutes of total time is spent on the date of the encounter) with modifier 25. Notice that the case involves just one diagnosis code.

“A separate diagnosis code is not necessary for the use of an E/M code with modifier 25,” says Chelle Johnson, CPMA, CPC, CPCO, CPPM, CEMC, AAPC Fellow, billing/ credentialing/auditing/coding coordinator at County of Stanislaus Health Services Agency in Modesto, California.

Key: The documentation must fully describe the additional E/M service. “If the documentation just supports the procedure, the use of an additional E/M with modifier 25 would not be appropriate,” she says. If you suspect the practitioner’s work warrants use of the modifier and their documentation does not, it’s important to communicate that to them directly so they fully understand what to document.

Documentation example: For an E/M service that is significant and separately identifiable from a procedure, an auditor is going to want to see that clearly in the notes. “If you’re a provider or you’re looking for something to communicate with your provider, I suggest a paragraph to physically separate the two services,” says Jeffrey Lehrman, DPM, FASPS, MAPWCA, CPC, CPMA, principal, Lehrman Consulting LLC, Fort Collins, Colorado. “This is my suggestion as an auditor. Begin the paragraph with something like this: ‘patient has a separate complaint today…,’ then after documenting the evaluation and management of that complaint, the last sentence should be, ‘This evaluation and management of the _________ was significant and separately identifiable from the procedure of ____________,’” he says.

Grasp the Cigna Difference

Cigna’s proposed policy would require documentation in the form of office notes supporting the use of modifier 25 each and every time you separately bill an E/M established patient office or other outpatient visit (CPT^® codes 99212-99215) with a minor procedure performed in the same session.

“The E/M line will be denied if Cigna does not receive adequate documentation to support that a significant and separately identifiable service was performed,” the insurer writes in its reimbursement policy. “The documentation should be submitted with a cover sheet indicating the office notes supports the use of modifier 25 appended to the E/M code.” The policy would require you to either submit the office notes via dedicated fax number or via email, which is rife with potential HIPAA violations.

What’s more, the notes must also follow the right documentation guidelines. “E/M services provided must meet the criteria as defined in the current CPT^® E/M guidelines for code section 99202-99215 and 1997 CMS documentation guidelines,” the insurer has added to its reimbursement policy for modifier 25.

Response: The American Medical Association (AMA), represented by Robert D. Otten, Vice President, AMA Health Policy, and more than 60 other national physician and healthcare professional organizations sent a letter to Cigna urging the insurer to “immediately rescind” the policy because of its “negative impact on practice administrative costs and burdens across medical specialties and geographic regions, as well as its potential negative effect on patients.”

Understand Modifier 57 Difference

Much of the coding advice in this article is equally applicable to modifiers 25 and 57 (Decision for surgery). The modifiers serve the same function: showing that a significant, separate E/M service preceded any other codable procedure or service.

Key: The main difference between modifiers 25 and 57 is the global periods attached to the procedures that follow the E/M. If the provider performs a procedure with a minor (0- or 10-day) global period, you’d append modifier 25 to the E/M code. For procedures that have a major (90-day) global period, you’d append modifier 57 to the E/M code.