Oncology & Hematology Coding Alert

Who knew that one little modifier could do so much damage for coders? Put modifier -25 on your claims, and you'll have payers up in arms. But defend your modifier -25 claims right from the start and you can avoid those timely denials.

The easiest way to report and get paid for modifier -25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) is to clean up and clarify these claims before they go out. Here's how.

1. Append modifier -25 only to E/M services. Do not use it on any procedure codes. You should use modifier -25 with an E/M service that's performed on the same day by the same physician as another procedure, says Sandra Soerries, CPC, CPC-H, director of healthcare compliance services for Tait Advisory Services in Kansas City, Mo. Many coders understand this concept, but in the flurry of getting claims out, they accidentally append the modifier to a procedure code.

2. Do not append modifier -25 to E/M codes when the only other codes for that claim are for ancillary services, like echocardiograms (EKGs) and x-rays. Also, some carriers restrict the use of modifier -25 to an E/M coded with a surgical service. Because there is some variation in this area among payers, please consult your local carrier for its specific policy.

3. Include separate documentation for both your E/M and procedure codes. You need to show medical necessity that justifies reporting both the E/M code and the procedure code(s). So, you must have separate documentation for both, Soerries says.                                                                                  

If you bundle your procedure note into the examination component of the E/M documentation or even tag it in the decision-making component, you could be losing legitimate revenue, she warns.                                                                

"It is always strongly recommended that if you are tying to justify that you are doing a separate procedure from the E/M service, you should have a separate procedure note, but it doesn't have to be on a separate sheet of paper," says Susan Callaway, CPC, CCS-P, an independent coding consultant in North Augusta, S.C. Rather, you should have a separate paragraph for the procedure note so your insurance carrier will know you really provided the patient with two separate and distinct services if you are reviewed, she adds. You should also remember that when using modifier -25, you should have all of the elements of the exam documented and that the E/M service's diagnosis code reflects medical necessity.

4. If you're still not getting paid, contact the representative for the relevant payer. Mary Dykstra, RT, CPC, billing manager at Medical Center of Stafford in the Roanoke, Va., area, has problems getting claims paid that include modifier -25. She finally called a representative at Blue Cross Blue Shield, who told her that the patient's BCBS program does not recognize modifier -25 or E codes. At this point, turn the problem over to your billers. When Dykstra's office billers appeal the claim, they ask for charts to justify the need to report both codes. Their denial is reversed 95 percent of the time.

It's still a lot of work for billers, so make their job easier by having all your charts and documentation in order when it's time to appeal.