Otolaryngology Coding Alert

Here’s your top ‘do’ and ‘don’t’ for correct usage.

Appending modifiers to your claims can better explain your otolaryngologist’s services and possibly boost your bottom line – or can lead to denials or other problems when used improperly. Increase your chances of success by steering clear of two common traps when reporting 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).

The proper use of the modifier 25 use continually becomes of increasing importance as the definitions and bundling changes with minor procedures and E/M services,” 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. “As of CCI 19.2 (July 2013), just about all minor procedures were bundled with E/M services (column 2 codes). It seems that CCI did not consider the definition that a minor procedure includes a small E/M service as an adequate rule showing that the related E/M is bundled with the minor procedure. So, CCI decided to further clarify the bundling beyond the minor procedure global period and added these bundles.” 

Starting point: Modifier 25 can only be reported when the physician performs a separate and significantly identifiably E/M service in addition to a minor procedure or service during the same encounter. When you’re able to report both services, append modifier 25 to the pertinent E/M code.

Don’t Automatically Include Modifier 25

Seeing that the otolaryngologist performed a procedure and E/M service during the same encounter doesn’t mean modifier 25 always applies. This has always been important, given the definition of the minor procedure global period, and is even more important now that E/M services are bundled with the minor procedures.

“The -25 modifier doesn’t need to be appended to every E/M service just because something else was done during the visit,” says Suzan (Berman) Hauptman MPM, CPC, CEMC, CEDC, manager of physician compliance auditing for West Penn Allegheny Health System in Pittsburgh, Pa. “The guidelines and instructions illustrate that only when a procedure with a minor global period is performed on the same day as a separately identifiable visit does the modifier have to be appended. I think practices trip over this because they’re afraid the other service will interfere with the payment of the E/M service.”

Caution: Don’t rely on only the fee slip communication when appending modifier 25. “Make certain that there’s documentation in the medical record to support the procedure as well as the separate E/M service,” Hauptman advises.

Plus: According to CMS rules, you can connect the same diagnosis with both the procedure and the E/M service as long as the documentation supports medical necessity for both but you will find that it is easier to justify both services if you have different diagnoses for the E/M service and the minor procedure.

Example: The otolaryngologist performs a comprehensive history, expanded problem focused exam, and the encounter has medical decision making of moderate complexity. During the problem focused exam, the physician indicates in the “Larynx” bullet that there was “inadequate visualization on mirror exam so it was decided to perform a flexible laryngoscopy” There is also a procedure note that demonstrates that he performed a flexible laryngoscopy and shows the findings from the performance of this diagnostic procedure. The patient came in with complaints of a lump in her throat and the physician does not find anything remarkable on completion of the flexible endoscopy. The final diagnosis is “globus.”  

This service would be coded as:

• 99123-25  784.99 (Other symptoms involving head and neck)
• 31575  784.99 (Other symptoms involving head and neck)

Caution: There is a chance that the payer may not pay the E/M with the 25 modifier and the procedure (the flexible larynogoscopy) with the single diagnosis. If this should happen, appeal the underpayment with the notes which show that the decision to perform the flexible laryngoscopy was performed during the E/M service and that it was a separate service.  Also point out that the E/M service is a “separate significant identifiable E/M as demonstrated by the enclosed chart documentation”

Do Confirm Medical Necessity 

“I find that the biggest problem with modifier 25 is inappropriate use, meaning it’s used with an E/M code when there wasn’t sufficient medical necessity to perform an E/M to perform the minor procedure,” says Catherine Brink, BS, CMM, CPC, CMSCS, president of Healthcare Resource Management, Inc., in Spring Lake, N.J. “In other words, there’s insufficient documentation to support the E/M code.”

Example: A patient is scheduled for a post-operative debridement after FESS surgery. The endoscopic debridement is scheduled and planned. Even though a small E/M is documented and performed, it is not really a separate and significant identifiable E/M service. As such, even though there may be a fully documented E/M service and fully separately documented endoscopic debridement (31237 Nasal/sinus endoscopy, surgical; with biopsy, polypectomy or debridement [separate procedure]), the E/M cannot support the 25 modifier and only the 31237 should be coded and billed.