Neurology & Pain Management Coding Alert

Fix your documentation or you'll find yourself in a fix

The HHS Office of Inspector General (OIG) cast a spotlight on the use of modifiers 25 and 59, and the results weren't pretty. If you want to stay off the audit radar screen this year, documentation will be key.

Bad news: The OIG found a 40 percent error rate for modifier 59 (Distinct procedural service) in its sample of FY 2003 claims, and a 35 percent error rate for calendar-year 2002 claims using modifier 25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service). In both cases, the OIG is encouraging review of claims that use these modifiers, which means you can expect more prepayment and postpayment audits.

Know the Pitfalls

Out of the audited modifier 59 claims (representing a random sample of 350 code pairs), 15 percent didn't represent a distinct service, because -they were performed at the same session, same anatomical site, and/or through the same incision,- the OIG says. Another 25 percent of modifier 59 claims lacked enough documentation to support one or both of the services.

With modifier 25, the biggest culprit plaguing 34 percent of the 431 sampled claims was missing or incomplete documentation. An additional 27 percent of modifier 25 claims had documentation of the procedure but contained no record of the separate E/M. For example, procedural notes showed that the provider gave the patient a flu shot but contained no information about a separate E/M service.

Surprisingly, only 2 percent of these improper claims involved E/M services that weren't significant and separately identifiable, the OIG says. In other words, many practices are performing separately reimbursable services but falling short when it comes to proving their work in the documentation.

Carriers are already scrutinizing modifier 25, and many private payers have balked at paying for E/M services with modifier 25 for years, says Margie Vaught, CPC, CCS-P, MCS-P, a coding consult in Ellensburg, Wash. But many carriers haven't looked at modifier 59 for surgical services before, and providers may not be used to having their use of modifier 59 audited, Vaught says.

Divide Documentation and Conquer for 25

To sidestep the OIG's scrutiny of modifier 25, you first need to establish that a significant and separately identifiable E/M service occurred.

To evaluate whether this is the case, use the -HEM- test, says Laureen Jandroep, OTR, CPC, CCS-P,   CPC-H, CCS, director and senior instructor for CRN Institute, an online coding certification training center based in Absecon, N.J. -HEM- stands for -history, exam and medical decision-making.- All procedures include a mini-E/M visit related to the procedures, but a separate E/M should include its own HEM.

Once you determine that a full and distinct E/M has taken place, your job is still not done. -When you put the 25 modifier on, you-re telling the payer, -I have documentation to back it up,- - Jandroep says. One simple way to audit-proof your documentation is to get in the habit of using a basic line to separate the procedure from the E/M, she adds.

Another option: You may also want to consider developing separate forms for your most commonly performed procedures, says Barbara Cobuzzi, MBA, CPC, CPC-H, CHBME, president of CRN Healthcare Solutions in Tinton Falls, N.J. That way, the physician's procedural note is always separate from the E/M, and proving your case in an audit is a breeze.

Follow 5-Part Rule for Modifier 59

As Appendix A of CPT describes, modifier 59 should only be used when a different, more descriptive modifier is not available. As a result, 59 has gained the daunting reputation as -the modifier of last resort.- But you could be losing out on deserved reimbursement if you don't know when using modifier 59 is appropriate and justified.

A good starting point to determine if you should use  this last resort is to check your documentation for one of the following five criteria: different sessions or encounters, different sites/organ systems, separate incisions/excisions, separate lesions, or separate injuries.

Coding tip: You should also link different ICD-9 codes to the separate procedures when applicable, Vaught says.