Orthopedic Coding Alert

Here’s what to do when the patient has an unexpected pain increase.

To know when you’re on the right track with reporting 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), you need to:

• Verify the service is significant

• Check for additional work

• Look for service “pre-planning.”

Now take a look at the following coding examples and decide how you would handle them. Then check your answers against our experts’ advice.

Scenario 1: A Semi-Planned Follow-Up Visit

Your orthopedist sees Mrs. Jones in the office and gives her a prescription for pain medication to help her wrist pain. He says that if the medication doesn’t help, he’ll give her a wrist injection when she returns. Mrs. Jones returns two weeks later for the injection. Your physician completes another evaluation prior to administering the injection.

Code it: Because your orthopedist planned the follow-up visit for the wrist injection, you should not charge a separate E/M service or include modifier 25 on your claim unless the patient’s situation has changed.

Sometimes doctors will redo an evaluation the day of the scheduled injection. If nothing has changed with the patient regarding any new diagnoses or problems and the injection was actually planned, you should not code an E/M office visit with modifier 25. You shouldn’t code an E/M visit at all.

Scenario 2: An Unexpected Pain Increase

Your physician treats Mrs. Adams for a minor shoulder injury. She returns a few days later because her arm was re-injured during activity and she’s experiencing significant pain. The physician completes a full evaluation before prescribing treatment.

Code it: Mrs. Adams sees your physician for the second time because of shoulder problems; she’s experiencing a significant change in pain pattern because of the snatching incident. The new pain pattern means you might submit an E/M code with modifier 25.

She has a significant change in pain pattern that she can relate to a change in the HPI. This warrants another E/M service to determine if the incident caused more damage, experts say. Depending on the situation, the physician might need to change her plan of care.

If there is enough difference in her condition to merit more treatment (such as an injection to manage pain), you can report an E/M code with modifier 25 in addition to the injection. If there’s no medical necessity for a full history and examination, however, you shouldn’t bill for a new E/M service.

Scenario 3: An Unrelated Condition Visit

Your surgeon completes total hip arthroplasty on Mr. Brown. Six weeks after the surgery, Mr. Brown returns to your office and sees a different physician because of an ankle sprain.

Code it: Although Mr. Brown returned to your office within the 90-day global period, he came for a problem unrelated to the hip surgery and saw a different physician. Although some coders see the second visit as “separately identifiable,” experts warn that appending modifier 25 is incorrect.

You need to look at the basic rules for using modifier 25. The separate and identifiable E/M service must be provided on the same day as a minor procedure. The ankle sprain is unrelated to the hip arthroplasty, which has a 90-day global period.

If you don’t have a minor procedure during the visit for the ankle sprain, modifier 25 is inappropriate. The hip arthroplasty is a major procedure and has a 90-day global period.

Instead: Because the two problems are unrelated, you should report Mr. Brown’s visit for the ankle sprain with the appropriate E/M code and modifier 24 (Unrelated evaluation and management service by the same physician or other qualified health care professional during a postoperative period) instead of modifier 25.