Medicare Compliance & Reimbursement

Identify when you need to attach modifier 25 to an E/M service.

These days, it isn’t a matter of if you will face Recovery Audit Contractor (RAC) scrutiny, but rather when. So now is the time to shore up your coding — but where should you focus?

The Centers for Medicare & Medicaid Services (CMS) published some of the RACs’ findings in its July 2015 Medicare Quarterly Provider Compliance Newsletter. Based on that information, if your practice performs E/M visits with pulmonary services, or hydration therapy, you should solidify your coding know-how.

Double-Check Your E/M Claims

In the publication, CMS covers some of the most problematic issues that the RAC auditors see, and among them is billing a limited E/M without modifier 25 (Significant, separately identifiable evaluation and management service by the same physician or other qualified health care professional on the same day of the procedure or other service) on the same date as a pulmonary diagnostic procedure (94010-94799).

The RAC found overpayments involved with this billing pattern, CMS notes, and if your physician obtains a limited history and exam on the same visit as a pulmonary function study, you should not report an E/M code along with the code for the pulmonary function test.

“If a significant, separately identifiable service is performed unrelated to the technical performance of the pulmonary function test, an E/M service may be reported with modifier 25,” CMS says in the compliance alert.

Example: A 57-year-old man with heavy smoking history presents to the pulmonologist’s office for the first time with shortness of breath (786.05). On clinical examination, he shows signs of underlying emphysema (492.8, Other emphysema). The pulmonologist orders spirometry to define the severity of his obstructive lung disease. You’ll report 94010 (Spirometry, including graphic record, total and timed vital capacity, expiratory flow rate measurement[s], with or without maximal voluntary ventilation) linked to 786.05. You’ll also bill the appropriate E/M code such as 99204 linked to the diagnosis code that reflects the reason for the separately identifiable E/M that the physician performed to diagnose and evaluate the patient’s underlying respiratory condition, emphysema (492.8). Append modifier 25 to 99204.

RACs Hunting for Hydration Therapy Diagnoses

In the Quarterly Compliance publication, CMS also points out that RACs evaluated several hydration therapy claims that were missing valid diagnoses. Many of the audits resulted in accusations of overpayments, which the providers are now expected to reimburse.

If you perform hydration therapy (such as 96360, Intravenous infusion, hydration, initial, 31 minutes to 1 hour), make sure you code the patient’s diagnosis to the highest level of specificity to avoid payment interruptions. The audit report indicates that several practices billed for this service using truncated diagnosis codes.

For example, if your patient suffers from vomiting, don’t simply report 787 (Symptoms involving digestive system). Instead, get specific by adding a fifth digit to indicate the type of vomiting, such as 787.01 (Nausea with vomiting) or 787.03 (Vomiting alone). The local coverage decision for 96360 covers these five-digit diagnoses, but not the three-digit code 787 — so those extra two numbers could be the key to unlocking your practice’s hydration therapy payment.

Resource: To read the entire Medicare Quarterly Provider Compliance Newsletter, visit www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/MedQtrlyComp-Newsletter-ICN909220.pdf.