Otolaryngology Coding Alert

Hint: Know your global periods.

Your physician assistant is probably an integral part of your ENT practice, and it’s essential that his modifier 25 billing stays on the straight and narrow. One recent analysis of these claims can give you some insight on how to ensure that you’re reporting these modifiers correctly.

Background.  The OIG took a random sampling of 450 claims out of 29 million and discovered that 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) was commonly abused, costing CMS millions.

“The OIG found 35 percent of the services provided did not meet Medicare program requirements, which resulted in improper payments of $538 million,” said Tamara Canipe RN, clinical quality management coordinator with Palmetto GBA CBR in a recent webinar. “OIG also found that a large number of claims with modifier 25 were appended, when no other service was performed on the same day. While the claims were not overpaid, they were filed incorrectly.”

Palmetto GBA’s CBR Group Acts on OIG Study

Due to the scope of incorrectly billed claims with modifier 25 and the excessive improper payments paid out, Palmetto GBA’s Comparative Billing Reports (CBR) group, in coordination with eGlobal Tech, released CBR 201611, which evaluated the data of over 12,000 Medicare Part B providers who billed for established patient E/M visits performed by physician assistants (PAs) when modifier 25 was appended. The CBR aims to address the issues with modifier 25 and analyze trends when it is used with five different CPT® codes related to PAs.

Problems with modifier 25. “Modifier 25 is a CPT® modifier and should only be appended to an E/M service,” Canipe explained, and herein lies the issue. Across the spectrum of the studies at both OIG and within different state agencies, Palmetto GBA found disparities and confusion related to things like subspecialties, global periods, and using modifier 25 “when no other conditions were serviced.” PAs cannot report using subspecialties, and each state and MAC determines what services they will cover, the CBR notes.

Here is the Global Surgery Caveat

Another factor Palmetto GBA unearthed in its research concerns global days, and how these distinct periods affect appending modifier 25. Distinguishing between minor and major procedures can be tricky, but checking the global surgery packages will help you avoid modifier 25 problems.

Minor service. For example, a patient comes in for a simple nasal foreign body removal, but while in the office, she also presents with ear pain. You evaluate the ear pain which was radiating down the jaw and determine that she is suffering from Eustachian Tube Dysfunction as a result of Acute Sinusitis and you prescribe the patient an antibiotic and nasal steroid spray. This removal of the foreign body from the nose is a minor procedure under the 000-010 global day period, and it can be billed with the E/M service attaching modifier 25.

Major procedure. The next level of care at, say, a 090-day global surgery package will likely be more serious, she advises. If the doctor sees a patient and decides to do surgery either the same day or the next based on his initial evaluation, you’ll report the E/M service with modifier 57 (Decision for Surgery).

CCI instructions specifically indicate, however, that the 25 modifier cannot be used because it is the decision to perform a procedure.

“Modifier 25 should be reserved for the unexpected,” Canipe explains. She goes on to clarify that documentation is key, and the notes must clearly state that to use modifier 25 the service must be a “stand alone” issue. Here is a quick reference guide Palmetto GBA mentions, devised by the American Academy of Family Physicians (AAFP) to ensure you are billing this correctly:

• Do you have the specifics of the separate identifiable issue in your notes?
• Is this a “stand alone” billable service?
• If your diagnosis is not different or unique to the original, do your notes validate the “extra work above and beyond the pre- or post-op work associated with the procedure?”

If your PA is reporting modifier 25 outside of these parameters, it may be a good idea to conduct an education session at your practice to ensure that they understand exactly how to use this modifier.

Resource: For more information on CBR 201611, visit http://www.cbrinfo.net/cbr201611.