Orthopedic Coding Alert

Carriers are scrutinizing modifier 25 claims this year, so append with caution

The Office of Inspector General (OIG) recently cast a spotlight on modifier 25 use, and the results weren't pretty. If you want to stay off the audit radar screen this year, documentation for your surgeon's modifier 25 claims will be key.

Bad news: The OIG found a 35 percent error rate for modifier 25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) in its sample of claims, so you can expect a lot more prepayment and postpayment audits.

Good news: You can tighten up your modifier 25 know-how with the following best practices from our orthopedic coding experts.

Modifier 25 Snafus Weren't for Obvious Reasons

Although coding educators frequently remind coders to append modifier 25 only during significant, separately identifiable E/M visits, some coders were surprised to find that only 2 percent of the claims that the OIG found to be billed improperly involved E/M services that weren't significant and separately identifiable.

Another 34 percent of claims that the OIG found billed improperly involved missing or incomplete documentation. -During my claim audits, I often find that the surgeon probably did the work to warrant modifier 25, but he doesn't have the documentation to back it up,- says Heather Corcoran, coding manager at CGH Billing Services in Louisville, Ky.

The OIG found that 27 percent of modifier 25 claims had documentation for the procedure, but not the separate E/M. For example, documentation showed that the provider gave the patient a shot, but no information about a separate E/M service. Another 4 percent were missing identifying information about the physician or patient.

Also, in 9 percent of cases (2.6 million claims), the provider used modifier 25 even though the E/M visit was the only service billed that day, meaning the modifier was unnecessary.

-This is a common case of what we call -just in case- modifier usage,- Corcoran says. -A lot of practices are putting 25 on all of their E/M claims and 59 (Distinct procedural service) on all of their procedure claims. This is completely incorrect coding. You should only use these modifiers when warranted. Otherwise it will cause even more audits and accusations.-

Best practice: The surgeon should document the E/M and the procedure in separate paragraphs so the coder can easily identify the separate nature of them.

Check out the following examples of modifier 25 do's and don-ts, provided by Rebekah C. Constant, CPC, an orthopedic coder in Dartmouth, Mass:

When You Should Use 25

1. A new patient presents to the orthopedist for evaluation of knee pain. The orthopedist diagnoses the patient with osteoarthritis of the knee and discusses options for management, then the surgeon injects a steroid such as Depo-Medrol or cortisone.

In this case, modifier 25 is acceptable with the appropriate E/M code (99201-99205) because the examination was necessary to determine what was causing the patient's knee pain. 
 
2. An established patient with a documented diagnosis of shoulder arthritis presents two weeks after her prior visit. She states that despite the pain-relief prescription that the surgeon previously provided, her pain has unfortunately worsened.

The physician examines the patient and finds that she has developed bursitis or tendonitis in the shoulder. The bursitis/tendonitis is a new diagnosis unrelated to the previously diagnosed arthritis. Modifier 25 would also be appropriate in this circumstance.
 
When You Cannot Use Modifier 25
 
An established patient presents to the office for a scheduled series injection such as Hyalgan.
 
The injection is the sole reason for the visit, so even though the surgeon talks with the patient about her progress prior to administering the injection, he cannot bill a separate E/M code.