Neurosurgery Coding Alert

Hint: Always keep a tab on global period assignments.

Don’t be disheartened if you have been facing repeat denials for modifier 25 (Significant, separately identifiable evaluation and management service by the same surgeon on the same day of another service or procedure). Here is how you can challenge these denials and justify your reimbursement for these services.

1. Does Documentation Meet Modifier 25 Criteria?

Verify that your surgeon’s chart note supports billing an E/M with modifier 25.

Basics: Minor surgical procedures are those that have a global period of 000 to 010 days. According to CPT^® guidelines, minor procedures have an allowance for E/M service built into the code (and reimbursement).

In order to be eligible to bill for an E/M service with a procedure, the documentation must show that the E/M performed was medically necessary as well as a significant, separate and identifiable service from the procedure or other service. “You report any significant and separately identifiable E/M service unrelated to the decision to perform the minor surgical procedure separately with modifier 25 and document the same,” says Marvel Hammer, RN, CPC, CCS-P, PCS, ACS-PM, CHCO, owner of MJH Consulting in Denver, CO. These rules apply to ‘new’ patients as well.

Hammer shares an example of a patient who was scheduled for cervical trigger point injections for myofascial pain:

“In this case, your surgeon also performs a separately identifiable and significant E/M service from the pre- injection / post-injection services associated with the trigger point injections.  The surgeon performs additional history, physical exam and medical decision-making in management of the patient’s chronic pain associated with their lumbar post-laminectomy syndrome.  The surgeon reviews the patient’s current medications and makes the medical decision to change some of the patient’s prescriptions to potentially better manage the patient’s chronic pain condition. The medication management for the patient’s chronic pain is separately identifiable and significant surgeon work from the services associated with the trigger point injections.”

Key: To also report an E/M code such as 99212-99215 (Office or other outpatient visit for the evaluation and management of an established patient ...), the provider must document a history, evaluation, and medical decision-making apart from that included in the injection.

Rule of thumb: If the E/M documentation can stand on its own, fight for modifier 25 pay.  According to CMS, E/M service with modifier 25 can have the same diagnosis as a minor procedure on the same day. The E/M service, however, should not include any work inherent in the additional procedure or the time spent for interpreting the results of the procedure. This is because there are times when an E/M may be a decision to perform a procedure. You can use this ground to file your appeal.

ICD-9 linkage: You should link the patient’s signs and symptoms with the E/M service and link any definitive diagnoses found with the scope with the procedure. If there are no definitive findings, you should also link the signs and symptoms to the procedure and (per CMS rules) use the same diagnosis for both the E/M service and the procedure.

Golden rule: When using modifier 25, remember this maxim: If you don’t have separate HEM (history, exam, and medical decision-making), you can’t bill an E/M.

In other words, the surgeon needs to determine whether the problem is significant enough to require additional work to perform the key components of the problem-oriented E/M service.

2. Review the Payer’s Rules

Some insurers will not pay for an E/M service in addition to certain procedures or other E/M codes, regardless of your documentation. And if your payer contract specifies these restrictions, don’t waste time appealing the decision.

If you continue to provide significant and separately identifiable E/M services on the same day as a procedure, you might want to keep track of what it is costing you in lost revenue to have such unfavorable terms with these payers. Capture your losses by entering the charges for the E/M services with modifier 25 and then immediately write them off to an adjustment code you create, such as “25NP” which stands for “25 modifier not paid.” That way, you can run a report at the end of the year highlighting all your “25NP” by payer, and capture the total lost revenue caused by each payer not complying with the AMA CPT^® code set. “Practices may consider having those patients come back on a different date for the E/M service, depending upon the flexibility of the provider’s schedule and the patient’s capability to come back,” says Hammer.

Once that has been quantified, you may want to consider re-negotiating your contracts when it is time for renewal.

3. Involve Others in Across-Board Rejections

But how do you know when a payer’s denials have gone from contract-approved denials to inappropriate activity? If an insurer never pays a modifier 25 service, find out why. Insurers should recognize that surgeons often have to provide a separate service with diagnostic procedures. If a payer consistently rejects modifier 25 claims, up the ante. Talk to the medical director and involve your local medical board.

Pointer: When requesting an appeal, ask for a board certified reviewer from your specialty. You’re entitled to have a reimbursement specialist familiar with your area of medicine analyze your information. The individual may better understand the separately identifiable nature of a service from an E/M.

Other sources: Inform your state specialty association and state medical society of the problem. You can also get support from national organizations such as the American Academy of Neurology.

4. Submit Coding Support

When you appeal a modifier 25 decision, remind the payer of two facts:

• HIPAA code set standardization requires that government and third party payers use ICD-9 and CPT^® as the official code set and CPT^® clearly defines the appropriate use of modifier 25. If your contract with the payer excludes modifier 25, the company violates HIPAA. The insurer is excluding part of the HIPAA code set. You may check with your payer for the same.
• You have submitted the claim based on documentation that supports using modifier 25. Include a copy of CPT^®’s Appendix A - Modifiers description of modifier 25 along with a standard form letter.