Neurosurgery Coding Alert

Effective Oct. 30, 2000, evaluation and management (E/M) services are considered bundled to a multitude of procedures unless they are significant and separately identifiable and have modifier -25 (significant, separately identifiable evaluation and management service by the same physician on the same day as another procedure or service) attached.

The new policy, which was proposed by the Health Care Financing Administration (HCFA) in the Nov. 2, 1999, Federal Register, has been implemented in version 6.3 of the national Correct Coding Initiative (CCI). More than 57,000 codes are affected by the policy shift.

When the new policy was proposed, HCFA said it was designed to prevent the practice of physicians reporting an E/M service code for the inherent evaluative component of the procedure itself. According to HCFA, the basis for this policy is that, because every procedure has an inherent E/M component, for an E/M service to be paid separately, a significant, separately identifiable service would need to be documented in the medical record.

The following codes, used often in neurology practices, are a just a few examples of services affected by this edit:

95970 electronic analysis of implanted neuro-
stimulator pulse generator system (e.g., rate, pulse
amplitude and duration, configuration of wave form,
battery status, electrode selectability, output
modulation, cycling, impedance and patient compliance measurements); simple or complex brain, spinal cord, or peripheral (i.e., cranial nerve, peripheral nerve, autonomic nerve, neuromuscular) neurostimulator pulse generator/transmitter, without reprogramming;

95971 simple brain, spinal cord, or peripheral
(i.e., peripheral nerve, autonomic nerve, neuromuscular) neurostimulator pulse generator/transmitter, with intraoperative or subsequent programming);

95972 complex brain, spinal cord, or peripheral
(except cranial nerve) neurostimulator pulse
generator/transmitter, with intraoperative or
subsequent programming, first hour; and

95974 complex cranial nerve neurostimulator pulse generator/transmitter, with intraoperative or subsequent programming, with or without nerve interface testing, first hour.

Tiffany Z. Eggers, JD, MPA, policy director and legislative counsel for the American Association of Electrodiagnostic Medicine, adds that modifier -25 must be appended even if the E/M and the procedure are performed at different locations. She also cautions that physicians who do not use the modifier may be accused of performing medically unnecessary procedures or fraudulent billing.

Currently, a coalition led by the American Academy of Neurology and representing the American Academy of Sleep Medicine, American Academy of Physical Medicine and Rehabilitation, American Association of Electrodiagnostic Medicine, American Clinical Neurophysiology Society, American Society of Electroneurodiagnostic Technologists, American Society of Neurophysiological Monitoring, and the National Association of Epilepsy Centers, is continuing to meet with HCFA in hopes of gaining a reversal of this policy. As of Oct. 30 despite the added time and effort that will be required for practices to gain a full understanding of what procedure codes are bundled with E/Ms initiating proper use of modifier -25 is imminent.

Audits and Other Risks

The new version 6.3 CCI edits that resulted from HCFAs new policy should not affect physicians who already bill the E/M separately from the diagnostic or medicine service provided only when it is significant and separately identifiable. For these providers, the only significant burden will be to look up the comprehensive code in the CCI and, if the E/M is bundled, to attach modifier -25. Until now, the E/M could be separately billed without the modifier. Practices in the habit of routinely billing E/M services when diagnostic tests or other medicine services are performed should take note that modifier -25 claims are closely watched by HCFA.

HCFA maintains that concerns about the policy triggering both routine use of modifier -25 and more appeals are exaggerated. Our experience with the coding instruction associated with the modifier -59 (distinct procedural service) [shows] no evidence that practitioners are routinely billing modifier -59 with multiple procedures performed on the same day by the same practitioner If the use of modifier -59 had become routine, we would expect to see an increase in expenditures because of the increased use of the modifier. This has not been the case.

HCFA did not comment on the increasing attention it gives both to modifier -59 and existing modifier -25 claims. It insists, however, that the requirement to use modifier -25 in those instances when the E/M service is distinguishable from the pre-procedure work may actually strengthen claims for payment. This result may persuade other third-party payers to recognize this coding guideline, thereby ensuring more consistency in payment. In addition, HCFA urges all practitioners to familiarize themselves with modifiers and use them appropriately.

Cindy Parman, CPC, CPC-H, co-owner of Coding Strategies Inc., a Dallas, Ga.-based consulting firm that supports more than 500 physicians nationwide, says that documentation is important when using modifier -25. Payers view -25 as an abused modifier, Parman says, and they are looking for inappropriate billing. Parman adds that if the carrier sees a distinct pattern of incorrect or inappropriate billing, the physician may become a prime target for auditing. This is not the only concern.

Many physicians dont realize that payers track a practices use of codes to create a provider profile, says Parman, who previously worked for a major commercial third-party payer for 20 years performing auditing and PPO contracting. They know on average how many visits a provider will charge in a given month that have the -25 modifier attached. Once you move radically outside their expectations by billing a greater number of visits with the -25 modifier than before, or by modifying your profile in any like manner, you raise payer awareness. Parman says that carriers may then ask for documentation on claims that have already been paid, and if the documentation does not justify that all the criteria for using the -25 modifier have been met, the carrier will be able to place the provider in a potentially financially draining payback position.