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Oncology & Hematology Coding Alert

Stop Modifier -25 Headaches Before They Start

Published on Fri Oct 08, 2004

Documentation must prove a separate E/M service

If your oncologist takes a bone marrow biopsy and performs a separate evaluation and management service on the same patient on the same date, the E/M service is often reportable using modifier -25.

But be warned: If you don't use the modifier correctly, you could open your office to a long appeals process, a denial - or even an audit.

Improper use of modifier -25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) has been on the rise in the past decade, and it has made regulators take notice. In 2003, the Department of Health and Human Services instructed its Office of the Inspector General (OIG) to start paying extra attention to modifier -25 claims to try to catch some people who were taking advantage of this method to bypass the bundling edits.

However, experts contend that if you do things right the first time on your modifier -25 claim, you'll have no reason to sweat the OIG and will reduce the chances of denial, regardless of insurer.

Proving Separate Service Is Priority 1

The most difficult modifier -25 issue is ensuring that the E/M service is actually separate from the other procedure, not just a component of the procedure, according to Lisa Center, CPC, of Freeman Health System in Joplin, Mo.

"Each service - the E/M and the procedure - needs to be able to stand alone [on the claim]. That is the point of the -25 modifier, to show that it is a separately identifiable service," Center says.

E/M for Chemo Nausea = Reportable Service

Take a look at this modifier -25 case provided to us by Tracy Sweat, CPC, of Piedmont Oncology Specialists, II, PLLC in Charlotte, N.C.

Let's say a patient now undergoing chemotherapy for multiple myeloma reports to the office for a bone marrow biopsy. When checking in at the front desk, the patient also reveals that he has had severe nausea attacks since the chemo began a month ago. The oncologist performs the biopsy, and then provides level-two E/M service for the nausea attacks.

Because the time and expertise the doctor expended on the patient's nausea were totally separate from the biopsy, you can report the E/M service and the procedure. On your claim, you should:

  • report 38221 (Bone marrow; biopsy, needle or trocar) for the biopsy.

  • attach ICD-9 code 203.0x (Multiple myeloma) to code 38221.

  • report 99212 (Office or other outpatient visit for the evaluation and management of an established patient, which requires at least two of these three key components: a problem-focused history; a problem-focused examination; straightforward medical decision-making) for the E/M service.

  • attach ICD-9 code 787.0x (Nausea and vomiting) to 99212.

    Remember: The reason you can report a separate E/M service is that the nausea was caused by something other than the bone marrow biopsy. Any pre- and/or post-procedure work related to the scheduled biopsy is included in the surgical procedure code and is not separately reportable as an E/M.

    Good Notes Make Rock-Solid Claims

    Documentation is often the glue that binds a successful modifier -25 claim, and expert oncology coders know that you should attach a paper trail to any modifier  -25 report.

    "The physician should dictate a separate office note for the E/M service provided on the same day that the patient also receives [separate] treatment," Sweat says. The "office note" Sweat references is vital to the success of any modifier -25 claim, says Audrea Burke, CPC, of Altru Health System in Grand Forks, N.D.

    "The physician must be able to document a separate service; some coders recommend a separate paragraph discussing the significant, separately identifiable E/M service ... or preferably a separate page," Burke says. The modifier -25 definition states, "significant, separately identifiable service."

    Report Modifier -57 for Surgical Decision

    One time you should not use modifier -25 is when the oncologist performs a separate E/M service and then decides to perform surgery on the basis of that evaluation.

    When the oncologists decides on surgery in the course of an E/M service, you should use modifier -57 (Decision for surgery) on your claim, Burke says. You would append   modifier -57 to an E/M service when the physician performs a major surgical procedure on the same day - this is typically a surgery that has a 90-day global period.

    Rule of thumb: Apply modifier -25 to E/M codes only. If the oncologist decides to operate, then it is no longer an E/M service and you should not report it with modifier -25.

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