Otolaryngology Coding Alert

Question: Does the E/M code for a procedure performed on the same day as an auditory brainstem response (ABR) require modifier -25?

California Subscriber

Answer: Some carriers may require it because recently changed Medicare guidelines in the Correct Coding Initiative (CCI) state that modifier -25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) should be appended to diagnostic tests with XXX global days. However, no edits (bundled code pairs) were introduced in the body of the CCI, so modifier -25 may not be necessary for many carriers. Even if modifier -25 is not needed, E/M services should be billed only if they meet the requirements of modifier -25 (are significant and separately identifiable). The routine evaluation performed before the test does not qualify as significant or separate and should not be billed using a separate E/M code. If, however, the E/M service determined the need for the ABR, it is considered significant and separate and could be reported on its own. Depending on the carrier, modifier -25 may be required.

You Be the Coder and Reader Questions were answered by Andrew Borden, CPC, CCS-P, CMA, reimbursement manager for the department of otolaryngology at the Medical College of Wisconsin in Milwaukee; Barbara Cobuzzi, MBA, CPC, CPC-H, an otolaryngology coding and reimbursement specialist and president of Cash Flow Solutions, a medical billing firm in Lakewood, N.J.; Lee Eisenberg, MD, an otolaryngologist in private practice in Englewood, N.J., and a member of CPTs editorial panel and executive committee; Elaine Elliott, CPC, a coding and reimbursement specialist in Jensen Beach, Fla.; Ann Hughes, CPC, coding specialist with Mid-Vermont ENT, an otolaryngology practice in Rutland, Vt.; and Michelle Logsdon, CPC, CCS-P, a coding and reimbursement specialist in Toms River, N.J. q