Otolaryngology Coding Alert

New verbiage for modifier 25 doesn’t necessarily negate all your claims.

Billing E/M services with 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) on the same date of service as a minor procedure has been a prime target of insurers for years, but payer scrutiny—and coder confusion—have increased with recent updates to the rules coming from the government. Read on for the latest on what terminology changes earlier this year mean and how they’re affecting ENT practices.

Brush Up on Minor Surgical Verbiage Changes 

The NCCI (National Correct Coding Initiative) manual for 2013 revised the wording associated with reporting modifier 25 in conjunction with minor surgical procedures, effective January 1, 2013. The description of minor surgical procedures (with new verbiage underlined) states:

“If a procedure has a global period of 000 or 010 days, it is defined as a minor surgical procedure. E/M services on the same date of service as the minor surgical procedure are included in the payment for the procedure. The decision to perform a minor surgical procedure is included in the payment for the minor surgical procedure and should not be reported separately as an E/M service.

“HOWEVER, a significant and separately identifiable E/M service unrelated to the decision to perform the minor surgical procedure is separately reportable with modifier 25. The E/M service and minor procedure do not require different diagnoses.

“If a minor surgical procedure is performed on a new patient, the same rules for reporting E/M services apply. The fact that the patient is “new” to the provider is not sufficient alone to justify reporting an E/M service on the same date of service as a minor surgical procedure.”

“E/M billing with modifier 25 has always been a target in the past, but this most recent description seems a little more threatening and goes beyond the definitions found in AMA CPT^®,” says Barbara J. Cobuzzi, MBA, CENTC, CPC-H, CPC-P, CPC-I, CHCC, president of CRN Healthcare Solutions, a consulting firm in Tinton Falls, N.J. “It is getting more and more difficult to support the -25 with E/M and the minor procedures with this updated verbiage.”

Think Your Way Through It

The description change and greater payer attention don’t mean you should never report an E/M, modifier 25, and minor procedure on the same claim again. You should, however, take a closer look at things before doing so, to verify that the E/M can stand on its own.

“I interpret that as the visit is way beyond the small E/M that is associated with a minor procedure,” Cobuzzi explains. “This is a significant and separately identifiable E/M because, based on the modifier’s terminology, it is way more than the small history, exam, and MDM associated with a minor procedure. This means that just saying the physician decided to do the scope because of inadequate visualization (as has been used before) may not be enough to support E/M with modifier 25 with this new verbiage. We need to show that we did a significant E/M that is way more than associated with just doing a scope and unrelated to the reason for the EM service as the CCI definition states.”

Stand Firm on Diagnoses

Note that the expanded explanation for using modifier 25 with minor procedures does still say that you aren’t required to report different diagnoses when you submit an E/M and modifier 25 with the minor procedure code for services on the same date.  However, the explanation also states that the E/M must be for an “unrelated” reason. 

Key challenge: “It is very difficult to prove that the E/M was performed for an unrelated reason if only one diagnosis is used for both the E/M and the procedure,” says Cobuzzi. “This conflicting information is confusing a lot of practices and coders. However, there may be times when a patient has a suspected condition and upon performing a diagnostic procedure, the otolaryngologist finds that the patient is negative for his suspicion. In this situation, the physician may end up with only a sign or symptom for both the E/M and procedure since no final diagnosis was yet found. The note should reflect the suspected diagnosis for which the procedure is being performed, so that it is clear that that the procedure is being performed for an unrelated reason.”

According to the Global Surgery Fact Sheet from CMS, “Both the medically necessary E/M service and the procedure must be appropriately and sufficiently documented by the physician or qualified non-physician practitioner in the patient’s medical record to support the claim for these services, even though the documentation is not required to be submitted with the claim.”