Otolaryngology Coding Alert

Why 'significant' and 'separate' matter when you're using modifier -25

Payers are denying claims right and left that don't include sufficient medical-necessity documentation and modifier errors. But performing chart reviews can prevent denials and keep auditors off your doorstep.

Support Your E/M Codes

When reporting office visits, make sure the documentation supports the E/M service level you've billed, or you could end up returning money to the insurer.
 
"Most practices are overcoding, and their documentation is lacking in the history component," says Trish Bukauskas-Vollmer, CPC, owner of TB Consulting in Myrtle Beach, S.C.

For instance, the appropriate history documentation for a detailed E/M service should include "extended history of present illness" and "pertinent past, family, and/or social history directly related to the patient's problems."
 
Also, the level of medical necessity is critical when you're determining the appropriate E/M code. "Many codes get downcoded because of medical necessity," says Laureen Jandroep, OTR, CPC, CCS-P, CPC-H, CCS, director and senior instructor for the CRN Institute, an online coding certification training center.
 
Scenario: The physician bills a level-four established patient visit for treating intrinsic asthma (493.10). You code the visit as a 99214 (Office or other outpatient visit ... established patient). To justify 99214, the documentation should support the medical necessity (medical decision-making of moderate complexity) and at least a detailed history and/or a detailed examination. Also, the office visit should consist of 25 minutes of face-to-face contact with the patient and/or family, according to CPT guidelines.

Get the 3 R's You Need for Consults

You should report consultation codes (99241-99275) when another physician requests a medical opinion from your allergist, such as when a family practitioner requests your allergist's advice on managing treatment for a patient who is allergic to bee stings.

Otherwise, if a physician asks your doctor to "evaluate and treat" a patient, you should consider this a "referral" and assign new patient E/M codes (99201-99205), Bukauskas-Vollmer says.

Coding challenge: When you're reviewing the consultation you've coded, check your physician's consult documentation to ensure it contains these three key elements:
 
Request: The reason for the consult is always another physician's request for your allergist's opinion, which your doctor should document. "If they request the patient be treated, then it's a referral, not a consult," Jandroep says.
 
Review: When your allergist diagnoses a condition, such as hypertension (401.x), he should document this in the medical notes. A consultation always involves a suspected problem and an unknown course of treatment.
 
Report: The last step is the allergist providing the requesting physician with a report of his findings. Typically, the physician will suggest a treatment plan for the patient in the report.
 
"The three R's are important because this is what distinguishes a consult from an office visit," says Pat Larabee, CPC, CCP, a coding specialist at InterMed, a multispecialty healthcare network in South Portland, Maine. "Without documentation of the three items above, you will see insurance companies change the codes from consultations to new or established office visit codes."
 
If the medical documentation for your office's consultations is missing the three R's, you should educate your physician on the proper way to document these visits, or you should begin to report other appropriate E/M codes.

Don't Let Modifiers Wreck Your Claims

Even if you have solid documentation and your procedure coding is pristine, you'll face denials and trouble during audits if you're misusing modifiers.
 
"Modifier -25 is the most confusing and abused modifier" in most practices, Bukauskas-Vollmer says.
 
Tip #1: Be sure that you - and every coder and biller in your office - understand how to use the modifier. You can attach modifier -25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) only to E/M codes (for example, 99201-99215).
 
"Basically, anytime the physician provides an E/M service and a procedure, you should use modifier -25," Jandroep says.
 
Payers assume that any E/M you report on the same date as a procedure is included in the procedure, so the carrier won't pay separately for the E/M, Jandroep says.
 
Tip #2: Use modifier -25 for your allergist's E/M services only when they are "significant" and "separate from" a procedure or service, Larabee says. "However, if there is no significant workup from the procedure, then charge for the procedure only," she says.
 
What to do: If during an office visit for food allergy management the patient complains of recent onset of elbow tenderness, and the physician determines that the patient should receive an injection, you may be able to report the injection and E/M code. For example, you could assign 20605 (Arthrocentesis, aspiration and/or injection; intermediate joint or bursa [e.g., temporomandibular, acromioclavicular, wrist, elbow or ankle, olecranon bursa]) and 99213-25 (Office or other outpatient visit) for the E/M.