Ob-Gyn Coding Alert

Make the most of your claim using this modifier decision-maker tool When your ob-gyn provides an E/M service on the same date or during the global period of another procedure or service, you have to decide whether to use modifier 25 or 57. Learn how to differentiate these two similar modifiers and get your full reimbursement. Don't Fall Into These Traps Incorrectly using modifier 25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) and modifier 57 (Decision for surgery) will send your claim to Denial Land.

Red flag: Due to misuse and inadequate documentation, payers are now scrutinizing claims that include modifier 25, says Peggy Stilley, CPC, CAPPM, CMC, ACS-OB, practice manager of Women's Healthcare Specialists, an Oklahoma University-based private ob-gyn practice in Tulsa.

Also, a failure to report modifier 57 with the E/M code when appropriate will result in lost reimbursement. -Using modifier 57 sets the E/M outside the global surgical package and allows payment for both services,- Stilley says. Learn the Difference You stand to lose if you don't know how to use both of these modifiers appropriately. The best way to understand them is to compare and contrast.

These modifiers are similar in that the ob-gyn performs an E/M visit on the same day as a procedure. Heads up: You should apply modifiers 25 and 57 only to the E/M code and never to a procedure code.

Here's the difference: -You should use modifier 25 on an E/M code to indicate that your ob-gyn did a minor procedure or other service on the same day as an E/M visit, and you should use modifier 57 on an E/M code to indicate that your ob-gyn and patient reached a decision for major surgery at the E/M visit--even though the visit falls in the 90-day global period for the surgery,- says Arlene Smith, CPC, insurance specialist with Tacoma Women's Specialists in Tacoma, Wash.

Hint: Minor procedures mean that the CPT code carries a global period of zero, 10 or -XXX- days. Major procedures, however, mean that the CPT has a global period of 90 days. -I always try to keep this in mind when deciding which modifier to use,- Smith adds.

Think you-ve got a handle on these two modifiers? Then challenge yourself below. Test Yourself With 2 Examples Read these two examples, decide whether you should use modifier 25 or 57, and compare your answer to what our experts say.

Example 1: A 17-year-old patient comes into the ED after an elective abortion elsewhere. Your ob-gyn has never seen her before. Your ob-gyn performs a D&C and admits the patient for intravenous antibiotic therapy. Which modifier should [...]