Neurosurgery Coding Alert

Understand 'significant' and 'separate' to move in the right direction.

Knowing when to report modifiers and choosing the best one for each situation can be an easy trip-up for coders. If you find yourself especially befuddled by modifier 25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service), keep reading for real-world tips that will help you code confidently every time.

Temptation: Some coders view modifier 25 as a "magic bullet," says Judith L. Blaszczyk RN, CPC, ACS-PM, compliance auditor with ACE consulting in Leawood, Kan.

She has heard from some coders that they "always add a 25 modifier to their E/Ms done on the same day as a procedure because that is the only way they can get them paid," Blaszczyk adds. Don't fall into that trap, she warns. "Any practice that applies modifier 25 indiscriminately to their E/Ms will be an outlier to other practices in the volume of claims billed with modifier 25 and will be sending up red flags."

Starting point: Remember you can only consider reporting modifier 25 when coding an E/M service. If the procedures you're reporting don't fall under E/M services, check whether the encounter qualifies for modifier 59 (Distinct procedural service) instead. Modifier 59 can be used only to distinguish one non-E/M procedure from another non-E/M procedure.

1. Verify That Service Is Significant

As CPT's Appendix A explains, a significant and separately identifiable service "is defined or substantiated by documentation that satisfies the relevant criteria for the respective E/M service to be reported." Ask yourself two questions when deciding if your case meets the criteria:

• Could the complaint or problem stand alone as a billable service? A single trigger point injection (20552, Injection[s]; single or multiple trigger point[s], 1 or 2 muscle[s]), for example, qualifies as a stand-alone service you might see in conjunction with an E/M visit.
• Do you have a different diagnosis for the portion of the visit unrelated to the initial service? For example, the patient might be in the office for a planned lumbar injection, but also complains of shoulder pain during the visit. Reporting an E/M code with modifier 25 would be appropriate for the services performed and documented concerning the shoulder.

If you can answer "yes" to either question, you're one step closer to reporting modifier 25.

Example: "My physicians complete a lot of lumbar and cervical injections that have a 0-day global period," says Mary Baierl, RHIT, CPC, CCA, CMT, a coder with BayCare Clinic, Pain Management and Rehabilitation Medicine in Green Bay, Wis. "When they evaluate the patient in the office, offer an injection, and have time to do the injection that day, we code the injection and include office visit E/M code with modifier 25 as a separately identifiable service."

2. Check for Additional Work

If the diagnosis remains the same, Quita Edwards, CCS-P, CPC, COSC, CPC-I, owner of CASE Contracting Services in Fort Valley, Ga., says you have another question to ask: Did your surgeon perform extra work that went above and beyond the typical pre- or postoperative work associated with the procedure code? Another affirmative answer points you to modifier 25.

Example: A patient comes to your office for a scheduled lumbar injection. She has received injections to treat leg pain due to sciatica but they don't provide long-term relief. During the appointment your physician says she needs to begin thinking about surgical intervention. He spends between 30 and 40 minutes discussing the risks and benefits of surgery so the patient can make an informed decision.

Even though the diagnosis you report for the injection and the E/M service will be the same, you can separately report the two services in this case. "The physician spent enough time discussing the surgery to count as significant and separately identifiable from the injection," Edwards explains. "You can bill an E/M code with modifier 25 based on the amount of time he spent, even though he didn't evaluate the patient."

3. Review Global Period Length

Another common point of confusion is between 25 and modifier 57 (Decision for surgery). You should only use modifier 25 with procedures that have a 0- or 10-day global period. These kinds of procedures are what Medicare defines as "minor."

In contrast, you'll use modifier 57 for an E/M service in which the decision for surgery is made in procedures with a 90-day global period, says Rena G. Hall, CPC, a coder and auditor with KC Neurosurgery Group in Kansas City, Mo.

Follow 57 guidelines: Use modifier 57 if the claim meets all of the following criteria:

• The E/M occurs on the same day of or the day before the surgical procedure;
• The E/M service directly prompted the surgeon's decision to perform surgery;
• The surgical procedure following the E/M has a 90-day global period;
• The same surgeon (or another surgeon with the same tax ID) provided the E/M service and the surgical procedure.

Coding example: A patient comes to the emergency room after a traumatic spinal fracture. The surgeon evaluates the patient and determines that a surgical treatment would be needed to treat the injury. If that procedure is performed the day of or the day after the evaluation service, the -57 modifier would be appended to the E/M service to alert the carrier that the E/M service is not bundled into the procedure but rather a separately identifiable service at which time the decision for surgery was made. A procedure with 90 day global period includes related E/M services performed during that period, but only AFTER the decision for surgery has been made.

Note: Because modifier 57 claims involve an E/M service that results in a decision for surgery, you would generally expect to see the same diagnosis code for both the E/M and the surgical procedure. The surgeon would most likely not make a decision for surgery based on a significant problem unrelated to the procedure.