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Oncology & Hematology Coding Alert

Manage Modifier 25 Troubles to Reap Better Reimbursement

Published on Tue Aug 09, 2005

Appropriate ICD-9 codes help prove your case to payers

If your oncologist performs and documents all the conditions for an evaluation and management service and provides a separate service, follow these three steps to learn when - and when not - to use modifier 25. Plus: We're offering a tool to help you win an appeal if a carrier denies your claim.

1. Identify the Right Time to Code Injection and E/M

In some circumstances, your oncologist can bill for both an injection and an office visit, even though Medicare may have bundled these services in the past. 

Anytime the oncologist performs an E/M in addition to a procedure you're coding, such as a chemo injection, append modifier 25 (Significant, separately identifiable E/M service by the same physician on the same day of the procedure or other service) to the E/M code if you need to tell your payer that the E/M is separate from the procedure, says Carolyn Davis, CMA, CPC, CCP,  CCS-P, CPHT, RMC, billing supervisor for Oncology Hematology West, and approved PMCC instructor for the AAPC, in her presentation "Using G Codes to Bolster Your Bottom Line."

Caution: Before you separate out the E/M with modifier 25, be sure the physician performed an exam that will satisfy coding and medical-necessity guidelines, says April Borgstedt, CPC, coding specialist and president of Working for You Consulting in Broken Arrow, Okla.

Medicare Transmittal 147 tells you that carriers pay for E/M services, other than CPT 99211(Office or other outpatient visit for the E/M of an established patient, that may not require the presence of a physician ...), provided on the same day as chemo administration or nonchemo drug infusion if:
 

  • you append 25 (even though the underlying codes don't have global periods), and
     
  • the E/M service meets the requirements found in Chapter 12, section 30.6.6 of the Medicare Claims Processing Manual.

    You'll find this Medicare transmittal online at www.cms.hhs.gov/manuals/pm_trans/R147CP.pdf.

    Heads-up: Coding guidelines and insurers' policies may not require that you use different diagnosis codes for the procedure and E/M when you append modifier 25, but doing so increases your chances of getting paid with some carriers, Borgstedt says.

    Example: If the patient presents for chemotherapy, cite the malignancy as his primary diagnosis (such as, 163.x, Malignant neoplasm of pleura). If the oncologist performs an E/M above the 99211 level because the patient complains of another medical issue, such as nausea and vomiting (787.01, Nausea with vomiting), link this diagnosis code to the E/M. 

    Special note: Even if insurers do require a separate condition or reason for the E/M service, make sure you don't artificially come up with diagnosis codes to support the separate E/M charge, says Marcella Bucknam, CPC, CCS, CPC-H, CCS-P, HIM program coordinator at Clarkson College in Omaha, Neb. The medical documentation should always support what the physician bills and the codes you use, she says.

    2. Master Varying Policies for Ancillary Services

    When the oncologist performs an office visit and then also provides an ancillary service, you typically don't need to use modifier 25 to separate the E/M service, Borgstedt says.
     
    Example: Along with an exam, the oncologist or his nurse performs a urinalysis, which is an ancillary service. The patient has prostate cancer but is exhibiting new symptoms that point to a urinary tract infection.

    In this case, you could report the appropriate E/M (such as, 99212, Office or other outpatient visit for the E/M of an established patient ...) along with 81002 (Urinalysis, by dip stick or tablet reagent for bilirubin, glucose, hemoglobin, ketones, leukocytes, nitrite, pH, protein, specific gravity, urobilinogen, any number of these constituents; non-automated, without microscopy) without using modifier 25.

    Quick tip: You should typically only use modifier 25 to unbundle an E/M service provided at the same time as a procedure with a 0- or 10-day global, Borgstedt says. Remember: Always be sure your documentation supports two separate services before you unbundle.

    Watch out: Not all private insurance companies follow CPT coding guidelines, Bucknam says. This means if an insurer requires that you attach modifier 25 to any E/M billed on the same day as a lab or x-ray, you should do it.

    Handy tool: If your office deals with several different commercial carriers, you're also probably dealing with several different sets of coding policies. To keep track of these policies, develop a chart that links each of the commercial insurance companies to their respective policies on modifiers for quick, easy use, Bucknam says.

    3. Use Our Appeal Letter to Fight Rejections

    If you think your insurance carrier has unfairly denied your modifier 25 claim and you want to appeal, you need a tried-and-true appeal letter to get your deserved payment.

    What to do: Try one of Oncology Coding Alert's templates for appealing modifier 25 denials. Send an e-mail to deborahd@eliresearch.com for a free template.

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