Orthopedic Coding Alert

Here's a look at a pair of common modifier 25 scenarios.

Individual cases always vary, but the majority of modifier 25 (Significant, separately identifiable evaluation and management service by the same physician or other qualified health care professional on the same day of the procedure or other service) claims involve two general types of patient encounters:

Same problem for E/M, procedure: In these instances, the provider performs an evaluation and management (E/M) service and a procedure for the same problem. These encounters often involve the same diagnosis, but that is not always the case. In these situations, you'll use modifier 25 to show that the E/M went above and beyond the normal pre- and postprocedure care associated with the procedure.

Different problems for E/M, procedure: In these instances, the provider performs an E/M and a procedure that are for completely separate patient issues. These encounters usually involve different diagnoses for the E/M and the procedure, but that is not always the case. In these situations, you'll use modifier 25 to show that the provider performed the procedure and the E/M for significantly separate reasons.

Check out these case studies for each of the above modifier 25 scenarios:

Same problem for E/M, procedure:

Consider this example from Catherine Brink, BS, CMM, CPC,  president of Healthcare Resource Management in Spring Lake, New Jersey:

A new patient reports to the orthopedist complaining of pain and swelling in his right shoulder. The physician performs an E/M service, which includes a detailed history and examination, along with moderate medical decision making (MDM). After the E/M, the clinician diagnoses bicipital tendinitis of the right shoulder, and performs an arthrocentesis joint injection to reduce the swelling. There is no evidence of ultrasound guidance.

For this encounter, the orthopedist had to examine the patient before arriving at the tendinitis diagnosis and performing the injection. Provided you have notes that prove that the physician needed to perform the E/M before deciding on the joint injection, you can report the following for the encounter:

• 20610 (Arthrocentesis, aspiration and/or injection, major joint or bursa [eg, shoulder, hip, knee, subacromial bursa]; without ultrasound guidance) for the injection
• 99203 (Office or other outpatient visitfor the evaluation and management of a new patient, which requires these 3 key components: a detailed history; a detailed examination; medical decision making of low complexity ...) for the E/M service
• modifier 25 appended to 99203 to show that the E/M and injection were separately identifiable services
• M75.21 (Bicipital tendinitis, right shoulder) appended to 20610 and 99203 to represent the patient's condition.

Different problems for E/M, procedure:

Here's another example, in which the provider treats two different problems during the same encounter:

Notes indicate that the provider performed a scheduled arthrocentesis joint injection for an established patient with bicipital right shoulder tendinitis. The provider performs the injection, and then the patient asks the provider to look at his left ankle, which has been hurting "for about a week." The provider performs an E/M to evaluate the ankle, which consists of an expanded problem focused history and exam, along with low-complexity medical decision making (MDM). The provider diagnoses left ankle pain for the E/M service after the injection. For this encounter, you'd report:

• 20610 for the injection
• M75.21 appended to 20610 to represent the patient's condition
• 99213 (Office or other outpatient visitfor the evaluation and management of an established patient, which requires at least 2 of these 3 key components: an expanded problem focused history; an expanded problem focused examination; medical decision making of low complexity ...) for the E/M
• modifier 25 appended to 99213 to show that the shoulder shot and the ankle treatment are significant, separately identifiable services.
• M25.572 (Pain in left ankle and joints of left foot) appended to 99213 to represent the patient's ankle pain.

Remember that on your modifier 25 claims "the physician must show, by documentation in the medical record, that on the day a procedure was performed, the patient's condition required a separately identifiable E/M service above and beyond the usual care associatedwith the procedure that was performed," reminds Mary I. Falbo, MBA, CPC, CEO of Millennium Healthcare Consulting, Inc. in Lansdale, Pennsylvania.