Otolaryngology Coding Alert

Appeals: HIPAA, CPT guidelines may convince insurer to pay up.

If an E/M denial lands on your desk, you shouldn't be caught scratching your head. Follow this expert advice to tackle those tricky modifier 25 appeals.

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). Every procedure has a small E/M built into it, experts say. So you must show that you performed a significant, separate 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.

Why: The National Correct Coding Initiative (CCI)'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, exam 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, provided no carrier policies disallow the particular code combination, such as a same diagnosis E/M with allergen immunotherapy. 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," says Victoria S. Jackson, practice management consultant with JCM Inc. in California.

Example: When your otolaryngologist performs an office visit that leads to a diagnostic laryngoscopy (31575, Laryngoscopy, flexible fiberoptic; diagnostic), encourage him to write two impression and plan notes, suggests Charles F. Koopmann Jr., MD, MHSA, professor and associate chair at the University of Michigan's department of otolaryngology in Ann Arbor. For instance, 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 plan could then note that a laryngoscopy is necessary to reach a definitive diagnosis.The 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," Koopmann says.

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.

Better method: Know your payers' rules. If your contract includes rules that require you to report services differently from CPT guidelines, you must follow them. But make sure to address these variations when your contract comes up for renewal. Payer bundles vary across the country. Midwest insurers don't impose too many modifier 25 restrictions, experts say.

Other insurance companies may require additional criteria. For instance, Louisiana Medicaid will not pay for an E/M service with a procedure, unless the codes contain different diagnoses, experts say. All other insurers in the same region pay.

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 a physician may sometimes have to provide a separate service.

If a payer consistently rejects modifier 25 claims, up the ante. Talk to the medical director, and involve your local medical board and medical society, experts recommend.

Tip: When requesting an appeal, ask for a specialty 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.entnet.org/.4. Submit Coding Support When you appeal a modifier 25 decision, remind the insurer of two facts:

1. HIPAA requires that government and third party payers use ICD-9 and CPT as the official code set. Because CPT clearly defines the appropriate use of modifier 25, the insurer must accept 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.