Otolaryngology Coding Alert

Remember Medicare has certain criteria to meet. 

It’s not unusual for an otolaryngologist to conduct an E/M visit and perform another service for the patient on the same day. If you’ll be filing the claim with Medicare, don’t assume that appending 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) is a fail-safe for reimbursement. 

Modifier 25 claims can only be successful if you establish the most vital element:  concrete proof that the procedure and E/M were truly separate, according to Catherine Brink, CMM, CPC, president of Healthcare Resource Management of Spring Lake, N.J. 

Verify that separateness by paying attention to three specific areas on the claim, and watch your claims succeed.  

Ensure an Appropriate Level of Service 

Every minor procedure includes a bit of E/M service in the global period. Because of this, the E/M care must be for reasons other than a simple 5-minute or less pre-op service that is assumed to be part of any visit. Help determine the level of service by asking yourself questions such as: 

• Did the physician evaluate the patient for a new prescription or re-evaluate him to renew an old one? 
• Did the physician address a new problem that the patient reported during that session? 
• Did the physician order tests or schedule other procedures for later that day to treat another known problem? 

In the second quarter of 2013, the Correct Coding Initiative (CCI) added another layer connecting the E/M service to the minor procedure.  The CCI last spring added a column 1 / column 2 bundle which bundles established E/M, inpatient E/M and nursing facility E/M services into minor procedures. This creates an additional level of bundling on top of the minor procedure global period, which makes it even more difficult to support reporting modifier 25 since the documentation must demonstrate that you have valid support for overriding the CCI bundle.

Coding tip: When you submit a claim with modifier 25, remember to pair it with the E/M code, not the code for the other service the physician performed. 

Watch for Multiple Diagnoses 

Medicare doesn’t require you to document separate diagnoses supporting the E/M service and the procedure the physician performed that day – but having them could streamline the payment process. 

Example: This could happen in an “oh by the way” situation when the patient mentions an additional problem or concern when being seen for a separate reason. You would report the signs and symptoms with the E/M code and modifier and the definitive diagnosis with the procedure code.

Verify the Presence of Separate Notes 

Before you submit your claim with modifier 25, be sure the physician writes separate reports for the procedure (the operative report) and the E/M visit. They might sometimes complain about the extra paperwork, but they should be willing to cooperate when they realize how it affects their bottom line.  The procedure’s procedure note can come immediately after the E/M note in the chart. That’s where you’ll usually find the information, especially with an EHR (electronic health record).

Example: The otolaryngologist performs an office visit that leads to a diagnostic laryngoscopy (31575, Laryngoscopy, flexible fiberoptic; diagnostic). In the initial impression, the otolaryngologist should document the patient’s problems, such as hoarseness and dysphagia, and note that the diagnosis is inconclusive. The bullet for the larynx and perhaps the oropharynx, hyperpharynx, pharynx, may indicate that findings are inconclusive because of gag reflex on mirror exam. But, that’s not enough. The note should indicate why it is medically necessary to perform the scope. Just indicating a gag reflex is insufficient. Putting the findings of the laryngoscopy in the exam will cause the payer to properly deny the separate nature of the scope from the E/M service.  It is critical for the note to show what was done during the E/M and why it is necessary to perform the procedure. 

The plan should then note that a laryngoscopy is necessary to reach a definitive diagnosis. A second set of notes should describe the assessment that the otolaryngologist reached from performing the scope, as well as the treatment plan. This two-tiered approach shows that the E/M led to the decision that the patient required the laryngoscopy. 

The physician isn’t required to write the notes on a separate sheet, but visually separating the service and procedure will help show you whether the E/M meets the test of water.

Final heads-up: Not all payers will reimburse for the separate E/M service even if you comply with all the modifier 25 coding rules. When this happens, be ready to appeal any denied claims. Make sure you have impeccable documentation from your physician as it will be put under a microscope when evaluated for an appeal. It is critical to see a separate history, exam and MDM as well as a procedure note. Medical necessity for the procedure must also be clear in the documentation. A second look by your payer could actually result in a decision to your favor.