Otolaryngology Coding Alert

4 tips show you what to do when you get that E/M denial.

The next time you don't know what to do with an E/M denial, take these four actions:

1. Check Documentation Meets Modifier 25 Criteria

You should first verify that your otolaryngologist's chart note supports billing an E/M with modifier 25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of another service or procedure). Per CPT guidelines, minor procedure has a small E/M built into it. In order to be eligible to bill for an E/M service with a procedure, the documentation must show that the E/M performed was medically necessary as well as a significant separate and identifiable service from the procedure or other service.

Example: A patient presents for an allergy injection, such as 95115 (Professional services for allergen immunotherapy not including provision of allergenic extracts; single injection) in the arm. The procedure has a little bit of evaluation in it. To also code an E/M, for instance 99212-99215 (Office or other outpatient visit for the evaluation and management of an established patient ...), the otolaryngologist must document a history, evaluation and medical decision-making apart from that included in the injection. Suppose the patient complains of ear pain at the time of the injection. As a result, in addition to the allergy shot, the physician sees the patient, and performs a history, exam and medical decision making related to the otalgia. Therefore, the E/M service the physician provided was significant and separately identifiable from the allergy shot and therefore supports modifier 25.

Why does an allergy shot with an E/M service require a modifier: The Correct Coding Initiative's introduction in version 7.2 made 'xxx' global period procedures, such as injections, require modifier 25 on a significant, separate E/M. The language defines that a procedure with 'xxx' global days includes a small amount of history, evaluation and medical decision-making similar to minor procedures.

Tip: If the chart note's E/M documentation can stand on its own, fight for modifier 25 pay. Even CMS states that an E/M with a 25 modifier can have the same modifier as a minor procedure on the same day. This is because there are times when an E/M may be a decision to perform a procedure. Use this CMS rule as part of your appeal, if necessary. You don't have 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. If you are performing a procedure that you perform regularly, such as a diagnostic nasal endoscopy or laryngoscopy, however, it is not a bad idea to use a templated procedure note.

Example: When your otolaryngologist performs a diagnostic procedure (such as, a diagnostic laryngoscopy, 31575), the chief complaint, history, and exam usually lead to the decision to perform the procedure. The payer should see that progression to decide to do the scope and that the encounter was not for a planned laryngoscopy. The physician should document the history including complaints such as hoarseness and dysphagia. He should also document a full history of present illness along with review of systems and a relevant past family social history. Then, based on the medical necessity, the physician should perform and document an appropriate exam. When the physician documents the laryngeal, he should also note the decision to perform the scope. For example, a physician may note that he decided to perform a laryngoscopy due to inadequate visualization on indirect mirror exam due to gag reflex. This documentation will give the otolaryngologist credit for the larynx bullet. Then, in a separate area, or on a procedure template form, he should document the laryngoscopy in order to get credit for the 31575. With the exam and medical decision making documentation completed, the note would support an E/M with a 25 modifier and 31575.

ICD-9 linkage: You should link the signs and symptoms with the E/M service and link any definitive diagnoses found with the scope with the procedure. If there are no definitive findings, you should also link the signs and symptoms to the procedure and per CMS's rules, you should use the same diagnosis for both the E/M service and the procedure.

2. Review Payer's Rules

Some insurers will not pay for an E/M service in addition to certain procedures or other E/M codes, regardless of your documentation. And if your contract specifies these restrictions, you shouldn't waste time appealing the decision. If you continue to provide significant and separately identifiable E/M services on the same day as a procedure, you might want to keep track of what it is costing you in lost revenue to have such unfavorable terms with these payers. You can capture your losses by entering the charges for the E/M services with modifier 25 and then immediately write them off to an adjustment code you create, such as "25NP" which stands for "25 modifier not paid." That way, you can run a report at the end of the year, highlighting all your "25NP" by payer, and then you can capture the total lost revenue caused by each payer not complying with the AMA CPT code set.

Once that has been quantified, you may want to consider re-negotiating your contracts when it is time for renewal.

3. Involve Others in Across-Board Rejections

But how do you know when a payer's denials have gone from contract-approved denials to inappropriate activity? If an insurer never pays a modifier 25 service, you should find out why. Insurers should recognize that otolaryngologists often have to provide a separate service with diagnostic procedures. If a payer consistently rejects modifier 25 claims, up the ante. Talk to the medical director and involve your local medical board.

Tip: When requesting an appeal, ask for a board certified otolaryngologist reviewer. You're entitled to have an otolaryngology reimbursement specialist analyze your information. The individual may better understand the separately identifiable nature of a service from an ENT E/M.

Other sources: Inform your state otolaryngology association and state medical society of the problem. You can also get support from the American Academy of Otolaryngology-Head and Neck Surgery (AAO-HNS) at www.entlink.net as well as the Association of Otolaryngology Administrators, (www.aoanow.org )

4. Submit Coding Support

When you appeal a modifier 25 decision, remind the insurer of two facts:

1. HIPAA Code set standardization requires that government and third party payers use ICD-9 and CPT as the official code set. Because CPT includes modifiers as part of the code set and CPT clearly defines the appropriate use of modifier 25, the insurer must accept the modifier and pay based on the correct use of the modifier.

If the payer's contract excludes modifier 25, the company violates HIPAA. The insurer is excluding part of the HIPAA code set.

2. You have submitted the claim based on documentation that supports using modifier 25. Include a copy of CPT's Appendix A - Modifiers description of modifier 25 along with a standard form letter.