Ob-Gyn Coding Alert

To ensure additional reimbursement and fewer denials when using modifier -25, make sure you can demonstrate that your E/M encounter and your other procedures are separately identifiable.
 

By using modifier -25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service), you're asking for separate payment for an E/M service that the ob-gyn performed on the same day as a procedure or other service. Just make sure you have the documentation to prove it.
 
Follow these three simple steps to determine whether you've made your case for using modifier -25:

1. Prove You Can Separately Identify the Service

CMS dictates that all procedures that include a global package (0, 10 or 90 days), from simple laceration repairs to common diagnostic tests, have an inherent E/M component. Consequently, Medicare will not pay you for an additional E/M service unless it is significant and separately identifiable and goes beyond the E/M service you would normally provide as a part of the procedure.
 
Some practices wrongly define "significant" to mean the E/M visit must be at least a level-four or level-five code (for example, 99204 or 99215, Office or other outpatient visit for the evaluation and management ...). But the September 1998 CPT Assistant states, "To use modifier -25 correctly, the chosen level of E/M service needs to be supported by adequate documentation for the appropriate level of service ... modifier -25 is not restricted to any particular level of E/M service."
 
"The 'significance' is that the problem warrants further workup or treatment, regardless of the complexity of the problem," says Carol Pohlig, BSN, CPC, RN, senior coding and education specialist at the University of Pennsylvania department of medicine in Philadelphia. "You should not report an E/M in addition to the procedure if the physician is commenting on self-limiting or minor problems that did not require a plan of care."
 
So you should append modifier -25 to your E/M code if the ob-gyn believes that he or she performed an E/M service that was completely independent of the procedure. But you don't have an E/M visit if the physician hasn't documented history, exam and medical decision-making. The doctor should clearly delineate these in addition to any notes about procedures performed.
 
To demonstrate that the E/M service qualifies as an independent evaluation, you should physically separate the E/M notes from the procedure documentation in the medical record. The ob-gyn should document the history, exam and medical decision-making in the patient's chart and record the procedure notes on a different sheet attached to the chart. Using this documentation method, a reviewer can clearly identify the two services, each of which is individually supported by documentation.
 
"Far too often, the ob-gyn will perform a procedure during a patient's annual well-woman exam and simply make a brief mention of the procedure in the documentation of the annual exam," says Judy Richardson, RN, MSA, CCS-P, a senior consultant at Hill and Associates, a coding and compliance consulting firm in Wilmington, N.C. By documenting two distinct notes, the physician ensures that if a payer questions what was billed, you can easily find the supporting documentation, she adds.

2. Think You Need a Separate Diagnosis? Think Again

The modifier -25 requirement that an E/M service must be "separately identifiable" is CMS' attempt to differentiate E/M services included as part of a larger procedure from those that go beyond the usual pre- and postprocedure evaluation and care. Ob-gyn coders occasionally interpret this to mean they must have a second, distinct diagnosis to bill a separate E/M service. Although Medicare does not require a second diagnosis, some private insurers do, Pohlig says.
 
Similarly, the E/M service doesn't have to be unrelated to the other service or procedure. "The E/M service may be prompted by the symptom or condition for which the procedure and/or service was provided. As such, different diagnoses are not required for reporting of the E/M services on the same date," CPT states. In all cases, however, if a second (related or unrelated) diagnosis is available, you should report it.
 
"When we are educating providers and the staff about using modifier -25, we tell them they should definitely report the service(s) if the service was prompted by something the ob-gyn found during the exam or the patient has presented with complaints or medical problems, regardless of the diagnosis," Richardson says.
 
For example, a patient presents for her routine follow-up visit one year after a total abdominal hysterectomy. During the visit, the patient states that she has had some recent discharge. Concerned by these developments, the ob-gyn takes an updated history, examines the patient and performs an ultrasound.
 
The documentation supports a level-three E/M service (99213) appended with modifier -25. You would also report the ultrasound with 76856 (Ultrasound, pelvic [nonobstetric], B-scan and/or real time with image documentation; complete) or 76857 (... limited or follow-up [e.g., for follicles]), depending on the type of ultrasound the ob-gyn performs.
 
Because the E/M service resulted from the same complaint that prompted the ultrasound, however, you would link the same diagnosis (such as 623.8, Other specified noninflammatory disorders of vagina) to both codes. Without modifier -25, the payer probably would bundle your E/M service into reimbursement for the ultrasound.
 
"As a coder who would like to prevent the claims from being delayed, I try to attach different diagnoses when possible," Pohlig says. "Although it may not be necessary, it illustrates the separateness of the services."
 
In the previous example, Pohlig notes that she would report the vaginal discharge code (623.5) with the E/M service because this prompted the physician's concern and plan for the ultrasound. "Reporting services with the highest level of specificity is inherent to ICD-9 coding," she adds.

3. Don't Confuse -25 With -57

Modifier -57 (Decision for surgery), like modifier -25, appends to E/M codes. But you should use -57 when the ob-gyn determines that he or she needs to perform a major surgical procedure (one with a 90-day global period) and will perform it either that same day or the next day, Richardson explains. You should use modifier   -57 particularly for Medicare patients because a major surgery's preoperative period starts one day prior to the surgery, she adds.