Neurology & Pain Management Coding Alert

Expert eliminates E/M application confusion.

Modifiers for evaluation and management (E/M) services are always tricky business, as there are rules and regulations specific to E/M coding that govern these modifiers. Knowing when to apply modifiers to E/M services is essential to avoid denials and fast track the reimbursement your practice deserves.

So, it’s always a good idea to check in with payers on a regular basis to see how they are interpreting guidelines and processing claims.

Recently, Part B payer NGS Medicare hosted a webinar — “Evaluation and Management Modifiers” — that provided a wealth of timely advice on three of the most used E/M modifiers that should answer most, if not all, of your frequently asked modifier questions.

Know Modifier Functions

“A modifier is a two-position alpha or numeric code added to the end of a CPT^® or HCPCS code to clarify the service being billed,” said NGS’ Michele Poulos during the call. “A modifier provides the physician with the means to indicate that a service or procedure has been altered by some specific circumstance, but not changed in its definition of the code.” Modifiers also help eliminate the appearance of duplication or unbundling, she added.

Keep in mind: The documentation must support the use of the modifier, and not all modifiers are recognized by Medicare.

Know Modifier Types

The modifiers fall into two main categories, Poulos notes. Pricing modifiers impact the payment amounts you’ll receive and should always be placed in the first modifier field. Informational modifiers, however, provide additional information regarding the service being performed, but do not affect the payment amount, and should be used in the second, third, or fourth field if a pricing modifier is also being used.

“The multicarrier systems used for claims processing allows up to four modifiers per claim line,” she added.

Know 24 Is for Unrelated E/Ms During Global

You’ll use modifier 24 (Unrelated Evaluation and Management Service by the Same Physician or Other Qualified Health Care Professional During a Postoperative Period) “when an unrelated E/M service or eye exam is performed by the same physician during the postoperative period of a procedure with a 10- or 90-day global period,” Poulos said.

You should never use modifier 24 for services rendered on the same day as the surgical procedure — in those cases, you’ll typically use 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) instead, Poulos said. In addition, you’ll never use modifier 24 for a complication of the original procedure, you can’t append it to the surgical procedure code, and it doesn’t apply to the removal of sutures or other wound treatment, since these are part of the surgical service. “These are all common denial reasons for this modifier,” she noted.

Documentation must support the fact that the E/M visit was unrelated to the postoperative care, and the diagnosis should clearly indicate the reason for the unrelated postoperative encounter, Poulos added.

Know 25 Is for E/M With Minor Procedure

“Modifier 25 may be appended to E/M services that are reported with minor surgical procedures with global periods of 0 or 10 days, or procedures not covered by global surgery rules,” Poulos said. Remember that the E/M service performed with the procedure must be both significant and separately identifiable to justify the use of modifier 25. Minor surgeries and procedures include pre-procedure, intra-procedure, and post-procedure work, so you should never report a separate E/M service for this work, she said.

“Remember that the fees for E/M services are already built into the surgical procedure, so you should be very cautious when you decide to use this modifier, and your physician should make that decision that in their professional opinion, the E/M service they’re providing is above and beyond the E/M service already associated with the procedure.”

Remember these best practices: If the patient sees one specialist for an E/M and another specialist for a procedure, then modifier 25 isn’t necessary, because the providers aren’t the same specialty, Poulos said.

Documentation must support the procedure as a separate and distinct service, and an appropriate ICD-10 code should be appended. “These services do not require a different diagnosis to be reported on the claim,” Poulos noted. “If you do have two separate diagnosis codes, you want to report them and use the diagnosis pointer on the claim to indicate which diagnosis code applies to which service, but it is acceptable to use just one diagnosis code.”

Know 57 Is for E/Ms With Major Surgery

“An E/M service that results in the initial decision to perform a surgery may be identified by adding modifier 57 [Decision for Surgery] to the appropriate level of E/M service,” Poulos said. This should be used for E/M services on the day of, or on the day before, a procedure with a 90-day global period, if the decision to perform the major surgery happens then.

“Certain situations may require the use of both modifiers 24 and 57,” she said. “This can occur when a provider is billing an E/M service resulting in the initial decision to perform a major surgery during the postoperative period of another procedure.”

Know the NCCI Edits

When appropriately billing these modifiers, keep an eye on the National Correct Coding Initiative (NCCI) edits, said NGS’ Arlene Dunphy, CPC, during the call. “The NCCI procedure-to-procedure code pair edits are automated prepayment edits that prevent improper payment when certain codes are submitted together for Part B covered services,” she said. These edits apply to all fee-for-service Medicare beneficiaries.

All line items for the same national provider identifier (NPI), date of service, and beneficiary are subject to the NCCI edits, so if a provider submits two codes from a pair together for the same beneficiary on the same date of service, the column 1 code is eligible for payment and the column 2 code is denied, Dunphy said.

However, if both services are clinically appropriate and an appropriate modifier is used on the column 2 code, then the service may be eligible for payment, Dunphy added. “But we would expect to see some supporting documentation in the beneficiary’s medical record to support the unbundling of those services. That could be a different session, different procedure or surgery — the information like that is going to support you unbundling those services.”