Otolaryngology Coding Alert

Another payer says it’s rarely allowable. 

With insurers seeming to constantly change their stances on certain procedures, keeping up with the latest policies can challenge even experienced coders. Read on for the latest from one payer in regards to 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) with E/M services. 

The situation: The payer posted on its website that, “Effective for dates of service on or after July 1, 2014, [the payer] will not compensate for evaluation and management services billed with modifier 25 on the same day as a procedure with a 0-day, 10-day or 90-day post-operative period if the member has been seen by the same provider in the last eight weeks for the same condition. Refer to the AMA’s CPT® Coding Manual for a description of appropriate use of modifier 25.” 

Interpretation: The policy applies to any situation involving a procedure with the stated global periods and an E/M service, regardless of whether the second visit involves a new complaint. 

Example: The otolaryngologist sees a patient for GERD and performs 31575 (Laryngoscopy, flexible fiberoptic; diagnostic). At that visit, you bill 31575 along with the appropriate E/M code with a 25 modifier. The patient returns within the eight-week time frame for a GERD check-up. You can submit 31575 for the second visit, but not include an E/M code. 

“The payer is saying it won’t pay for the E/M even if the patient has a completely unrelated compliant that might normally be reportable, such as an ear complaint for which the E/M is performed in addition to the scope for a GERD,” says Barbara J. Cobuzzi, MBA, CENTC, CPC-H, CPC-P, CPC-I, CHCC, president of CRN Healthcare Solutions, a consulting firm in Tinton Falls, N.J. 

Remember edits: Don’t forget that Correct Coding Initiative (CCI) edits bundled most minor procedures into established E/M services in 2013, so it’s much more difficult to justify billing an E/M and a minor procedure.  So, in the case where the patient comes back for a follow up for GERD with no other complaints, it is very hard to justify an E/M with a 25 modifier given the bundling in addition to the definition that a minor procedure includes a mini E/M.

Prior to the second quarter of 2013, the only reason to need a 25 was the definition of the minor procedure and the fact that it included a mini E/M service. As of Q2 2013, CCI added further burden of separateness by bundling the established E/M with the scopes and other minor procedures like 69210 (Removal impacted cerumen requiring instrumentation, unilateral). This does not apply to new patient, ED and xxx global procedure services with E/M codes. They still just have the mini E/M associated with them, but are not bundled with the E/M codes. 

“The thing is that we have to use the 25 modifier only when it is correct, when it applies based on both the definition of the minor procedure global definition and the bundling as of second quarter of 2013,” Cobuzzi notes. “Overuse of the 25 modifier is a red flag for audit, so you want to have documentation to back up whenever you report it.”