Otolaryngology Coding Alert

Know what circumstances do and don't warrant 25 use.

Even the most seasoned coders will admit that while there's a science behind the use of 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), mastering that science isn't a particularly easy feat. When working with modifier 25, it's important to look at each situation as its own separate entity rather than viewing common themes and scenarios under the same universal lens.

That's because there's always going to be some degree of ambiguity as to what defines a "significant, separately identifiable" service. While there are measures you can take to set yourself up for the best chance of success, there's no substitute for experience when working with a tricky modifier such as this one.

Read further to boost your experience using these three real-life examples of when and when not to use modifier 25.

Take Global Period into Account

Question: Can I bill out a 99213 consultation for ear pain with a modifier 25 if a pure tone audiometry threshold evaluation (air and bone) is also performed?

Answer: "92553 has an XXX global period, which means that the global concept does not apply," says Barbara J. Cobuzzi, MBA, CPC, CENTC, COC, CPC-P, CPC-I, CPCO, AAPC Fellow, vice president at Stark Coding & Consulting LLC, in Shrewsbury, New Jersey. "However, many years ago, Version 7.2 of the Correct Coding Initiative (CCI) edits added in its verbiage that XXX global period codes could be treated like minor procedures. Therefore, coders should consider a small 'preoperative' E/M encounter to be included in their value. The word 'could' is used because this rule in CCI is ultimately left up to the payer's discretion," details Cobuzzi

So, it ultimately depends on the payer when deciding whether or not to apply modifier 25 to 99213 (Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: an expanded problem focused history; an expanded problem focused examination; medical decision making of low complexity ...) when paired with 92553 (Pure tone audiometry [threshold]; air and bone).

Rely on Your Deductive Reasoning Skills

Question: A patient comes in for a weekly allergy injection and proceeds to spend 15 minutes with the physician regarding a sinus issue. Can I bill out 99213 in addition to 95117 (Professional services for allergen immunotherapy not including provision of allergenic extracts; 2 or more injections)?

Answer: Based on this description, the physician might have performed a significant, separately identifiable E/M service on the patient in addition to the allergy injection. However, since E/M codes are not based on time (unless counseling is documented to be over 50 percent of the time), the physician would have had to document a significant and separately identifiable expanded problem focused history, exam, and medical decision making of low complexity to support the 25 modified E/M service, 99213-25. As for diagnoses, you should attach the sinus diagnosis to 99213-25 and the allergy diagnosis to 95117.

Determine Whether the Service is Truly Separately Identifiable

Question: An established patient arrives for scheduled radiofrequency inferior turbinate reduction (superficial) procedure. Following the procedure, the patient complains of a sore throat. The physician evaluates the patient and documents an expanded problem focused history and exam. The doctor determines that the patient had an adverse reaction to the numbing agent used from the procedure.

Answer: This example does not warrant enough for the provider to report an E/M visit alongside code 30801 (Ablation, soft tissue of inferior turbinates, unilateral or bilateral, any method (eg, electrocautery, radiofrequency ablation, or tissue volume reduction); superficial).

Since the sore throat is a direct result from the turbinate ablation procedure, the follow-up consultation is a component of code 30801.

2 Traps to Avoid with Modifier 25

1. Do not use modifier 25 when you've already applied modifier 57 (Decision for surgery).

In circumstances where an E/M service results in the decision to perform a major surgery, Medicare guidelines state, "If evaluation and management services occur on the day of surgery, the physician bills using modifier '57,' not '25.' The '57' modifier is not used with minor surgeries because the global period for minor surgeries does not include the day prior to the surgery. Moreover, where the decision to perform the minor procedure is typically done immediately before the service, it is considered a routine preoperative service and a visit or consultation is not billed in addition to the procedure."

2. Do not use modifier 25 on an E/M service that occurs on a different day than a procedure.

Only use modifier 25 on an E/M service performed by the same physician on the same day as the accompanying significant, separately identifiable procedure. If the procedure falls on a separate day or a separate physician performs the procedure, do not include modifier 25 on the E/M service.