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 you use?

Answer: You should use modifier 57. -Since the treatment of the incomplete abortion (59812, Treatment of incomplete abortion, any trimester, completed surgically) carries a 90-day global period, you should use modifier 57 on the E/M service,- Stilley says.

As for the E/M code, you have several options depending what the ED physician does. If the ED physician doesn't report the ED visit (99281-99285), you can. If the ED physician does report the ED visit, you should fall back on a new outpatient visit code (99201-99205). If the ED physician requested a consult from your ob-gyn, you should report an outpatient consult code (99241-99245). For any of these coding choices, append modifier 57 to the E/M service to show that the ob-gyn decided to perform surgery during this visit.

Bonus info: You should count all subsequent care as part of the postoperative care following the surgical treatment of the incomplete abortion. Also, if your ob-gyn admits the patient to the hospital that day for the surgery, you should roll all services he performed into the admission code, to which you-ll append modifier 57. The exception to this rule would be if your ob-gyn documented a consultation. In that case, when the ob-gyn subsequently admits the patient, you should report an inpatient consultation code for that encounter with modifier 57.

Example 2: The ob-gyn sees a patient with vaginal bleeding. During the exam, the ob-gyn identifies polyps in the cervical os and decides to remove the polyps the same day instead of asking the patient to return. Which modifier should you use?

Answer: You should use modifier 25, Smith says. You should report the visit code (9921x) with modifier 25 appended in addition to 57500 (Biopsy, single or multiple, or local excision of lesion, with or without fulguration [separate procedure]). Appropriately appending modifier 25 means that your practice will receive separate payment for an E/M service that the ob-gyn performed on the same day as a procedure or other service.

Remember, you should use modifier 25 only if the E/M service includes more than the risks, benefits, and explanation of the procedure the ob-gyn is about to do, Stilley says. Make sure your ob-gyn's documentation of the E/M visit goes beyond these elements.

Use This Modifier Decision-Maker Tool

Choosing whether to use a modifier (either 25 or 57) can mean the difference between getting paid for your E/M service or settling for just the procedure fee. Try this handy checklist, care of our coding experts, and get your coding right every time:

Report both the E/M service and the procedure code if:

The ob-gyn decides to perform the procedure at the same encounter as the E/M service, regardless of the diagnosis (use modifier 57 for major procedures [>90 global days] or modifier 25 for minor procedures [<90 global days])

OR

The E/M service and the procedure have different diagnoses (append modifier 25 to the E/M code with a minor procedure or modifier 57 for a major procedure).
 
Report only the procedure code if:

The ob-gyn decides to perform the procedure at a different encounter than the one during which he performs the E/M service

OR

The E/M service did not require a separate and significant history, physical exam and/or medical decision-making.