Otolaryngology Coding Alert

HCFA has suspended edits of evaluation and management (E/M) services with diagnostic tests. The edits, published in version 6.3 of the national Correct Coding Initiative, became effective Oct. 30, 2000, and bundled 66 E/M codes with more than 800 diagnostic tests and other services listed in the Medicare fee schedule as having XXX global days.

When HCFA first announced its intention to bundle E/M services with diagnostic tests in the November 1999 Federal Register, it stipulated that if the E/M service was significant and separately identifiable, it would be separately payable if modifier -25 (significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) was attached to the E/M code.

The stated purpose of the edits was to prevent the practice of physicians reporting an E/M service code for the inherent evaluative component of the procedure itself. As a basis for its policy, the agency reasoned, Because every procedure has an inherent E/M component, for an E/M service to be paid separately, a significant, separately identifiable service would need to be documented in the medical record.

Physicians across the nation, however including otolaryngologists have reported an increase in denials of E/M services when performed on the same day as diagnostic tests (such as audiology and allergy tests) even when modifier -25 was attached.

Note: Version 6.3 of the CCI also bundled most E/M codes with the following services: operating microscope in the office; nasopharyngoscopy; nasal, facial nerve, and laryngeal function studies; evaluation and treatment of swallowing and oral function; vestibular function tests; airway obstruction treatment; continuous positive airway pressure initiation; sleep testing; speech testing; and some radiological supervision and interpretation codes that involve the ear, nose, throat, head and neck.

How Does the Suspension Affect Otolaryngologists?

For now, otolaryngologists should code audiology and other diagnostic tests performed on the same day as an E/M service as though the Oct. 30, 2000, edits never existed, says Lee Eisenberg, MD, an otolaryngologist in private practice in Englewood, N.J., and a member of CPTs editorial panel and executive committee.

If your Medicare carrier continues to deny E/M services on the same day as an audiogram billed without modifier -25 or without a separate diagnosis, contact your carrier or the American Academy of Otolaryngologists Head and Neck Surgeons, Eisenberg advises.

During the three months the edits were in effect (Oct. 30-Jan. 26), many otolaryngologists reported receiving denials and warnings from carrier representatives about attaching modifier -25 to E/M services performed with diagnostic tests, even though, according to Susan Callaway, CPC, CCS-P, an independent coding and reimbursement specialist and educator in North Augusta, S.C., the use of modifier -25 in such circumstances was mandated by HCFA.

Physicians and their specialty societies also report erroneous actions and instructions from carriers, including:

Automatic denials for E/M services performed on the same day as diagnostic tests;

Being told to attach modifier -59 (distinct procedural service) to the E/M service; and

Being told that two diagnoses are required for both services to be paid.

Some practices even report being asked for refunds for E/M and diagnostic tests previously paid.

HCFA has pledged to work with the AMA and specialty medical societies to continue educational efforts on correctly appending modifier -25 to E/M services when billed with diagnostic tests and other services with XXX global days performed on the same day.

HCFA also claims it will develop a program to guide and educate carriers, and will direct the carriers to publish clear and accurate information about the edits in local Medicare bulletins. Finally, the agency says it will attempt to ensure its carriers implement existing national policy that allows the same ICD-9 code to be associated with both the E/M service and whatever service or procedure has been provided on the same day.