Otolaryngology Coding Alert

Recoup same-day services with modifier -25

Are your forfeiting payment for office visits with audiology tests? You are if you're not appending modifier -25 to the E/M code, when appropriate.

To make sure you're not missing out on valuable evaluation reimbursement, consider three 92551 (Screening test, pure tone, air only) billing examples that also apply to other audiology exams (such as 92552-92557, ... audiometry threshold ...).

Scenario 1: Different Diagnoses and Providers

After failing a school hearing test and having chronic recurrent tonsillitis, a 10-year-old boy presents to an ENT for impaired speech. The otolaryngologist performs an E/M service (99213, Office or other outpatient visit for the evaluation and management of an established patient ...) and orders her audiologist to perform 92551. The test shows that the child's hearing is normal, and the physician schedules the patient for a tonsillectomy (42825, Tonsillectomy, primary or secondary; under age 12).
  
In this example, you should definitely report the office visit because the service is a significant, separately identifiable evaluation from the audiogram, says Rhonda Buckholtz, CPC, practice manager at Crawford and Fitch Ear, Nose and Throat in Franklin, Pa. Because you'll have two different diagnoses (474.00, Chronic tonsillitis for the E/M and 388.40, Abnormal auditory perception, unspecified), the payer should cover both the service (99213) and the test (92551) without difficulty, she says.

Why You Need Modifier -25

Make sure you append modifier -25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) to 99213 to show that the exam is a significant, separately identifiable service from the test (92551), Buckholtz says. Otherwise, you will lose money because the insurer may bundle 99213 with 92551. To get paid correctly, you may have to resubmit the claim, she says.

You need modifier -25 because the National Correct Coding Initiative version 7.3 changed the description of XXX global-day codes to include a small E/M component, says Barbara Cobuzzi, MBA, CPC, CPC-H, an otolaryngology coding and reimbursement specialist and president of Cash Flow Solutions, a medical billing firm in Lakewood, N.J. Translation: The test includes a minor, related E/M. "That means you should not separately bill for any history, exam and medical decision-making (MDM) that the audiologist performs as part of 92551," she says.

Scenario 2: One Diagnosis, One Provider

But what if a patient comes in for a otolaryngologist-ordered 92551 with the audiologist and no reason exists for the patient to see the physician during the visit?

You should report the test (92551) only, Cobuzzi and Buckholtz say. Because a medical reason doesn't require the otolaryngologist to see the patient, no significant, separately identifiable evaluation occurs from the screening test. Therefore, you shouldn't bill for an E/M (such as 99212-99215).

Scenario 3: One Diagnosis, Two Providers

A patient presents to an otolaryngologist after failing a school hearing exam. After the evaluation, the physician documents the medical necessity for 92551 and orders an audiologist to perform the test.

Although the service and procedure will have the same diagnosis - the results of 92551 - you should bill the E/M code appended with modifier -25 in addition to 92551, Buckholtz says.

To report an E/M in addition to 92551, you don't need multiple diagnoses. "Although different diagnoses will make payment easier, CPT does not require separate diagnoses to bill the service," Cobuzzi says. You should instead separately report the otolaryngologist's evaluation, provided the physician's service fits modifier -25's definition: The E/M counts as a significant, separately identifiable evaluation from the test.