Otolaryngology Coding Alert

Coding an E/M service with a minor procedure never ceases to stump even the most confident coding experts, so follow four tips to report these services without losing ethical reimbursement and committing fraud.

When an otolaryngologist provides a separate and significant E/M service and a minor procedure during the same visit, you should bill both services and 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 the E/M service. Modifier -25 indicates that the E/M is separate from and significant to any minor procedure that the physician also provides on the day of the visit, says Shirley Fullerton, CPC, supervisor of HIM (Medical Records) for the Valley Hospital Medical Center in Las Vegas. "The key words are 'separate and significant,' " she says.

Some insurance companies interpret "significant and separate" to mean that you must treat something different, says Susan Callaway, CPC, CCS-P, an independent coding auditor and trainer in North Augusta, S.C. "CPT states that this is not necessary, and Medicare does not require a different diagnosis." For instance, an emergency-room physician requests an otolaryngologist's opinion on whether a patient who has respiratory distress needs an emergency tracheostomy. The otolaryngologist performs a history, examination and medical decision-making and agrees that the patient requires a trach. You should report the tracheostomy (31603, Tracheostomy, emergency procedure; transtracheal) and the E/M (99241-99245, Office consultation for a new or established patient) appended with modifier -25. Although only one diagnosis, respiratory distress (518.82, Other pulmonary insufficiency, not elsewhere classified), exists, the E/M is allowable because the physician performed a separate service to determine the procedure's necessity.

Because CPT doesn't require a second diagnosis, many practices want to charge an E/M attached with modifier -25 in addition to cerumen removal (69210, Removal impacted cerumen [separate procedure], one or both ears) with an impacted cerumen diagnosis (380.4) only. "Cerumen removal doesn't pay well," says Barbara Cobuzzi, MBA, CPC, CPC-H, an otolaryn-gology coding and reimbursement specialist and president of Cash Flow Solutions, a medical billing firm in Lakewood, N.J. When cerumen removal can take 30 minutes or more on both ears, physicians feel that they're not paid adequately. Charging an E/M in addition to the removal, they reason, helps them obtain "entitled" reimbursement. You should not bill cerumen-removal-only visits this way, Cobuzzi says.

For instance, a patient comes in complaining that he can't hear well. The otolaryngologist looks in his ear, sees impacted cerumen and removes it, and this is all that is done and all that is documented. In this case, bill the cerumen removal (69210) only, she says: "The physician performed nothing else." You can't support a separate E/M service.

Further documentation does not necessarily support billing an E/M. The service, instead, must be medically necessary. If the doctor documents a history, examination and medical decision-making that contain nothing remarkable to support the medically necessity of performing that extra work, do not bill the E/M.

If the patient presents for an E/M visit that is separate from and significant to the minor procedure, however, you should bill both the E/M and the procedure, Fullerton says. For example, a patient presents with wheezing (786.07) and a fever (780.6) and also complains that he can't hear well. The otolaryngologist performs a level-three history, examination and medical decision-making and determines that the patient has an upper-respiratory infection. In addition, he removes impacted cerumen. For the service that led to the URI diagnosis, report the appropriate-level E/M, such as 99201-99205 (New patient office visit) or 99211-99215 (Established patient office visit), appended with modifier -25. For the cerumen removal, assign 69210. Make sure to link the E/M to the URI diagnosis (465.9, Acute upper respiratory infections of multiple or unspecified sites; unspecified site) and the cerumen removal to impacted cerumen (380.4).

Although reimbursement depends on your insurance contracts, carriers should pay for both services, Fullerton says. "HMO contracts often consider all services provided during a visit bundled or included in the visit or monthly capitation," she says. Practices should not reschedule such services to bill the procedure separately. The U.S. Office of Inspector General may consider such actions "over-utilization," which could trigger an insurance audit, she warns.

If you receive routine modifier -25 denials, create form letters for appeals but make sure the documentation will support the separately identifiable E/M. Cobuzzi uses separate form letters for new patients and established patients. New patients' needs differ from established patients' needs. When a new patient presents for cerumen removal only, the otolaryngologist must obtain information, such as patient medications and history, before proceeding with cerumen removal. Therefore, billing an E/M appended with modifier -25 is appropriate even though only a diagnosis of cerumen removal exists.

When reporting multiple diagnoses, make sure to link the appropriate diagnosis to the correct procedure/service. "With electronic billing, assume that most payers will look at the first diagnosis only," Cobuzzi says. If you list the diagnosis that supports the procedure lower, the carrier may deem the procedure or service medically unnecessary.

For instance, a patient complains of hoarseness. The otolaryngologist performs a flexible laryngoscopy and finds a polyp. Link the diagnosis for hoarseness (784.49) to the E/M (e.g., 99213-25) and the polyp (478.4, Polyp of vocal cord or larynx) to 31575 (Laryngoscopy, flexible fiberoptic; diagnostic). "Some check-out desks will list hoarseness first and the polyp second for the service and the procedure," Cobuzzi says. The carrier will not understand the reason for the laryngoscopy.

If the laryngoscopy reveals nothing, you should link both the service and the procedure to the diagnosis for hoarseness. This informs the payer that the physician didn't find anything. This is another example when the physician has only one diagnosis, but the documentation supports a separate E/M and procedure.

Know What the Surgical Package Includes

Much of the confusion regarding whether an E/M constitutes a significantly separate service stems from not understanding various payers' global surgical packages. You can't know if the E/M is separate unless you know what the carrier includes in the procedure.

Although CPT and Medicare rules vary, knowing each coding convention can help you understand a carrier's interpretation. CPT includes usual preservice and postservice care with small surgical procedures. For procedures that include the surgical package only, CPT places an asterisk next to the procedural code, which means the following rules apply:

1. The service includes the surgical procedure only. Related pre- and postoperative services are not included in the service.

2. Report a starred procedure and visit as follows:

(a) When you perform a starred procedure at the time of an initial or established patient visit involving significant, identifiable services, the appropriate visit is listed with modifier -25 appended to the E/M code in addition to the starred procedure.

(b) When the starred procedure requires hospitalization, list an appropriate hospital visit (e.g., 99221-99223, Initial hospital care) in addition to the starred procedure and its follow-up care. Although CPT does not specify appending modifier -25 to the hospital code in this situation, payers may require the modifier.

3. Add all postoperative care on a service-by-service basis, such as an office or hospital visit or a cast change.

4. Add all complications on a service-by-service basis (as with all surgical procedures).

For example, an internist requests that an otolaryn-gologist examine a patient who has parotiditis. The ENT performs a history and examination in his office. In addition, he drains the abscess and sends a written report to the internist.

The scenario is an example of (a) above. The doctor performed a starred procedure (42300*, Drainage of abscess; parotid, simple) at the time of an initial patient visit involving a significant, identifiable service (the history, examination and medical decision-making part of the E/M, which led to the decision to drain the abscess). Consequently, you should report the appropriate consultation (99241-99245, Office consultation for a new or established patient) appended with modifier -25 in addition to the starred procedure (42300).

Medicare uses global surgery indicators, rather than starred procedures, to indicate the care that a procedure includes. For minor procedures, such as cerumen removal, which carries a "000" indicator meaning zero global days, Medicare includes related preoperative and postoperative care on the day of the procedure. Medicare also uses "010," 10 global days, to indicate that the minor procedure contains pre- and postoperative care provided on the day of the procedure and 10 postoperative days. Therefore, if you report an E/M in addition to a minor procedure, the E/M must represent work that is not included in the procedure hence a significant, identifiable service.

Remember that the national Correct Coding Initiative version 7.3, October 2001, changed its global package verbiage. Because of Medicare's definition of minor preoperative care, CCI stated that procedures with "xxx" global days include a minor E/M, just like zero- to 10-day procedures. These "xxx"-days procedures are usually found in the medicine codes (90281-99600). Because of CCI's change, many payers require modifier -25 to show that the E/M is separately identifiable from your "xxx" procedure.

Let's look at how Medicare directs coding for the above example of the parotid with the consultation. The 2002 National Physician Relative Value Fee Schedule indicates that 42300 contains 10 global days, meaning the relative values for 42300 include related pre- and postoperative work on the day of the procedure and for 10 postoperative days. To indicate that the E/M is a significant, separately identifiable service, you would have to append modifier -25 to the consultation. Therefore, the coding is the same under either coding system.

Modifier -25 is necessary even when a procedure is not starred, Callaway says. "You need modifier -25 because payers set up their systems to look for a modifier whenever they see an E/M and a procedure to explain why both codes are there," she says. "It has less to do with whether the procedure is starred or not, and more to do with what the payer views as a minor surgical procedure. Most insurance companies lean toward Medicare's definition of a minor procedure and not CPT's starred-procedure terminology."

Separately Document Service and Procedure

Claims involving modifier -25 require clear documentation to inform the carrier that the physician provided a separate service. Documentation should include one section for the history, examination and medical decision-making (HEM) and one for the procedure. You should be able to draw a line between the service and the procedure, Cobuzzi says. For minor diagnostic procedures, such as scopes, documentation should include one section for the HEM and one for the scope. When the otolaryngologist includes the results in the examination section, coders have a difficult time showing that the physician performed the E/M for a separate, identifiable reason.