Otolaryngology Coding Alert

When an otolaryngologist performs a nasal endoscopy (31238) on a Medicare patient who comes in with symptoms of epistaxis (for example, 784.7 or 448.0), he or she typically takes the patients history, does some physical ENT examinations, and then decides the patient needs the endoscopy.

To bill for both the endoscopy and the E/M work, the ENT must file the 31238 and the E/M code (most likely a 99212 or 99213, office or other outpatient visit) with a modifier -25 (significant, separately identifiable E/M service by the same physician on the same day of the procedure or other service) attached to the E/M code.

This scenario may appear straightforward, but like so many coding issues, when it comes to reimbursement, there may be complications. Although modifier -25 is appropriately claimed in this instance, many physician practices and carriers are still confused as to how to correctly utilize this modifier, which many consider the most misunderstood and misused modifier ever.

Many ENT offices that OTC spoke with report confusion over when to use -25 or the related modifier -57 (decision for surgery: an E/M service that resulted in the initial decision to perform surgery), and about how commercial carriers, in particular, reimburse either or both claims.

Beth Sutton, a coding and reimbursement specialist in the office of otolaryngologist Paul Antalik, MD, in Pittsburgh PA, says some carriers want to see modifier
-57, even though the CPT code book definition indicates modifier -25 is more appropriate.

Some carriers seem to prefer -57, even when you do a simple procedure here in the office. And they wont pay when you use modifier -25, which is actually the correct way to code the claim, Sutton says.

Note: The use of modifier -25 is currently on the watch list of the federal Office of the Inspector General, and the Health Care Financing Administration (HCFA) now is actively auditing claims that contain this modifier. So utilizing it correctly is more important now than ever, as misuse could trigger an audit, repayment of previously paid claims and fines.

Modifier -57 should only be used when there is major surgery performed within a 90-day global package, according to Medicare guidelines, while modifier -25 is used for procedures with 0- and 10-day global packages.

According to Emily Hill, PA-C, a managing partner with Strategic Healthcare Services, a coding and practice management consulting firm in Bald Head Island, NC, modifier -25 should be used when an E/M service was provided above and beyond any E/M usually included in the procedure.

Hill, a member of the American Medical Associations Relative Value Update Committee and their CPT-5 Project and Correct Coding Policy committees, notes that modifier
-25, used properly, should identify an E/M service so that separate payment will be approved and obtained (remember modifier -25 is attached to the E/M code). Examples of such services include:

An evaluation when the decision to do the procedure was made. A routine examination of a patient with sinus congestion (99212-99214, office or other outpatient visit) prompts the physician to perform an endoscopy (31233, nasal endoscopy, diagnostic, with maxillary sinusoscopy [via inferior meatus or canine fossa puncture]).

More extensive E/M services. The patient comes in with a head bump and facial injuries, including a nosebleed that doesnt stop. The physician performs an examination to determine if the patient has a broken nose or closed head injuries (99213-99214). Ultimately, there was no broken nose, no head injury, only a nosebleed (30901, control nasal hemorrhage, anterior simple [limited cautery and/or packing] any method). However, a significant level of E/M services was performed.

For a different diagnosis. A boy comes in with typical cold symptoms (99212). During the exam, the physician discovers and removes a small bead from the childs ear (69200, removal foreign body from external auditory canal; without general anesthesia).

Tip: Hill recommends that a modifier -25 be included in such claims even if the carrier in question has a payment policy that differs from HCFAs and precludes payments for these two services on the same day. If [the physician] has provided both services, you should use the -25 modifier regardless of the payer because it accurately reflects the services provided, she says.

Attestation of Extra Work

Every time you go into a doctors office, theres some aspect of E/M that goes along with thatits an inherent part of the procedure that is built-in. When you bill in addition to that, youre saying, Ive gone above and beyond the typical E/M before a procedure.

In other words, Hill says, modifier -25 is a kind of attestation. Its like saying, I swear to you I really did something above and beyond the procedure.

She adds that physicians cannot bill E/M visits when they have pre-planned the procedure and the visit is part of the basic service provided.

As for modifier -57, Hill points to Medicare guidelines that indicate its appropriate use for a visit that resulted in the decision to perform a major surgical procedure that is covered by a 90-day global package.

A typical modifier -57 billing would result from a regular patient visit that led to an unplanned surgery, she says. The physicians examination would uncover a problem that required immediate or next-day surgery.

Modifier -57 tells the carrier that although the exam was initially thought to be routine, it resulted in a decision to perform surgery within the 90-day global period.

Hill notes that when the procedure is pre-planned and is essentially the only reason for the visit, neither modifier should be used.

However, if the patient came in for a pre-planned procedure and then presented with a new problem that was also evaluated, it is appropriate to bill an E/M visit to address the new problem.

In such a case, a new diagnosis code should be linked to the E/M code. Hill points to a clarification issued in CPT 1999 that says a physician may use modifier -25 to bill a visit and refer to the same ICD-9 code used for the procedure itself. Previous CPT books never explicitly said two separate ICD-9 codes were required; they were more vague on the issue.

Hill notes that even with the clarification, the diagnosis should be linked to the E/M code that is submitted along with the modifier. As with most claims, the documentation supporting the codes submitted should clearly indicate that both the procedure and E/M have been performed.

E/M services with attached modifiers, in particular, require careful documentation, Hill says, and she recommends submitting a procedure note that also documents the surgery or other procedure to accompany any supporting notes on the E/M visit.