Orthopedic Coding Alert

If you can demonstrate that your E/M encounter and your other procedures are separately identifiable, youll be on the right track to additional reimbursement and fewer denials when using modifier -25.

Modifier -25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) allows separate payment for an E/M service that you perform on the same day as a procedure or other service if you have the documentation to prove it. Follow these three simple steps from the experts to determine whether youve made your case for your modifier -25 claims.

1. Prove That the Service Is Separately Identifiable

CMS dictates that all procedures, from simple injections to common diagnostic tests, have an inherent E/M component.

Medicare will not pay you for an additional E/M service unless it is significant and separately identifiable and it goes above and beyond the E/M service you would normally provide as a part of the procedure.

Some practices define significant to mean that the E/M visit must be at least a level-four or -five code (such as 99204 or 99215, Office or other outpatient visit for the evaluation and management ...), but the September 1998 CPT Assistant states, To use modifier -25 correctly, the chosen level of E/M service needs to be supported by adequate documentation for the appropriate level of service, modifier -25 is not restricted to any particular level of E/M service.

So you should append modifier -25 to your E/M code if the physician believes that he or she performed an E/M service that was completely independent of the procedure. I always say, if you dont have an HEM (history, exam, and medical decision-making), you dont have an E/M, says Laureen Jandroep, OTR, CPC, CCS-P CPC-H, CCS, director and senior instructor for the CRN Institute, an online coding certification training center. There should be clear documentation of the HEM, in addition to any notes about procedures performed.

To demonstrate that your E/M service qualifies as an independent evaluation, you should physically separate the E/M notes from the procedure documentation in the medical record. The physician should document the HEM in the patients chart and record the procedure notes on a different sheet attached to the chart. Using this documentation method, a reviewer can clearly identify the two services, each of which is individually supported by documentation.

2. Dont Assume You Need a Separate Diagnosis 
 
The requirement that an E/M service must be separately identifiable is CMS attempt to differentiate E/M services included as part of a larger procedure from those that go beyond the usual pre- or postprocedure evaluation and care.

Orthopedic practices sometimes interpret this to mean that a second, distinct diagnosis is required to bill a separate E/M service, but this is incorrect, says Heather Corcoran, coding manager at CGH Billing Services, a medical billing firm in Louisville, Ky.

Likewise, there is no requirement that the E/M service must be unrelated to the other service or procedure provided. CPT specifically states, The E/M service may be prompted by the symptom or condition for which the procedure and/or service was provided. As such, different diagnoses are not required for reporting of the E/M services on the same date. In all cases, though, if a second (related or unrelated) diagnosis is available, you should report it.

For example, a patient presents for his routine follow-up visit one year after total knee replacement. During the visit, the patient states that he has been having knee pain and swelling. Concerned by these developments, the physician takes an updated history, examines the knee and orders an x-ray. Due to the presence of a large effusion, the surgeon aspirates the knee.

The documentation supports a level-three (99213) E/M service (with modifier -25 appended) in addition to the joint aspiration (20610*, Arthrocentesis, aspiration and/or injection; major joint or bursa [e.g., shoulder, hip, knee joint, subacromial bursa]).

Because the E/M service resulted from the same complaint that prompted the knee injection, however, you would link the same diagnosis (such as 719.06, Effusion of joint; knee) to both codes. Without modifier -25, the payer would probably bundle your E/M service into reimbursement for the injection procedure.

3. Avoid Confusion With Modifier -57

Like modifier -25, modifier -57 (Decision for surgery) appends to E/M services but should not be used for minor procedures performed with E/M visits. Modifier -57 is appropriate only if, during the patient evaluation, the physician determines that a major surgical procedure (a procedure with a 90-day global period) is necessary and will be performed either that day or the next day.