Oncology & Hematology Coding Alert

Hint: -000- and no global aren't the same thing

If you-re confused by CMS- 2006 clarification of using modifier 25 during the global period, join the club. Our coding experts set the record straight on when you should -- and shouldn-t -- use this modifier.

Problem: To recoup more reimbursement, many practices report an E/M code with modifier 25 (Significant, separately identifiable E/M service by the same physician on the same day of the procedure or other service) for patients who visit for any checkup or procedure, regardless of whether their situation really justifies modifier 25, says John F. Bishop, PA-C, CPC, president and CEO of Bishop & Associates Inc. in Tampa, Fla. As a result, there has been a major crackdown on this modifier by the OIG and private payers.

Solution: Before you code another claim, get yourself out of automatic modifier 25 mode if you-re in it. Then, take a fresh look at the claim and the reason the patient visited the office. Was she there for a checkup under a global? Was she there for a procedure? Was she there for a checkup or procedure and then asked the doctor to look at something completely different? Unless you can answer -yes- to the third question, you should think twice before adding modifier 25 to your claim.

Don't Trip Over Transmittal Language

In 2006, CMS released Transmittal 954, which covers -payment for evaluation and management services provided during global period of surgery.- (For the exact language, go to www.cms.hhs.gov/transmittals/downloads/R954CP.pdf to read the full transmittal.) 

Good news: The transmittal clarifies that you do not need a separate diagnosis for modifier 25 and that payers need not look for documentation of medical necessity unless they suspect a pattern of abuse, says Barbara J. Cobuzzi, MBA, CPC, CPC-H, CPC-P, CHCC, president of CRN Healthcare Solutions, a coding and reimbursement consulting firm in Tinton Falls, N.J. But you still need to have the documentation of medical necessity in your chart.

You may have also noticed the transmittal's instructions to use modifier 25 when your physician provides a significant and separately identifiable E/M service on the same day as a procedure with a global period.

Tricky: Some coders mistakenly take this statement to mean that they can't use modifier 25 on a separate E/M service on the same day as a procedure with a zero global. A zero global and an XXX global (no global) are not the same, Cobuzzi says. Minor procedures with zero global days have a built-in prework component with a history and physical -- that is, a minor E/M, a history, exam and medical decision-making, she says.

So if the situation calls for modifier 25, be sure to append it to the E/M accompanying a zero-global procedure as well as those with 10 global days or more.

Example: Code 31575 (Laryngoscopy, flexible fiberoptic; diagnostic) has a -000- global according to the fee schedule available at www.cms.hhs.gov/apps/pfslookup/.Oncologists often make a same-day decision to perform a laryngoscopy. A patient may present for a completely separate problem, and after the oncologist provides the E/M service he may decide a laryngoscopy is necessary.
 
In this case, you can bill for both the E/M (with modifier 25) and 31575 as long as the physician's documentation clearly explains the distinct reason for the laryngoscopy. Tip: The physician should provide a separate procedure note for the laryngoscopy so you have documentation that both services are separate and distinct.

The separate procedure note does not have to be a separate piece of paper, but should be at least a separate paragraph, rather than being buried in the examination portion of the E/M service.

Not OK: You cannot bill for both the E/M and 31575 if the patient comes in specifically for a laryngoscopy and the physician only takes the patient's vital stats but doesn't perform a full and separate E/M.

You would not use modifier 25 on an E/M accompanying an XXX-global procedure. Instead, you-d just report the services separately.

See if Your Payer Has Any Exceptions

A handful of payers might actually require you to append modifier 25 to the E/M in claims with XXX globals. Starting several years back with National Correct Coding Initiative version 7.2, the preamble to the initiative said that XXX-global-day procedures do have a minor E/M associated with them, just like zero-global-day procedures, Cobuzzi says.

And because of that, some payers require modifier 25 for a separately identifiable E/M service accompanying procedures with an XXX global.

The question is, will your payer decide to go with what NCCI says or with what CMS Transmittal 954 says? Verify this information before you code your next claim.

Resource: Read the OIG report on modifier 25, and its misuse, at http://oig.hhs.gov/oei/reports/oei-07-03-00470.pdf.