Otolaryngology Coding Alert

If you don't use modifier -25 correctly, you might face a long appeal process, refund requests, payment refusals, or, even worse, an audit. As long as you can demonstrate that your E/M encounter and your surgical procedure are separately identifiable, you'll be on the right track to additional reimbursement.

The HHS Office of Inspector General plans to scrutinize claims that include modifier -25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) this year, so you shouldn't append this modifier unless you're sure that your visit meets all of its criteria. Follow these three simple steps from the experts to determine whether you've made your case for your modifier -25 claims.

CMS dictates that all minor procedures, from simple injections to common diagnostic tests, include an inherent E/M component.

Medicare will not pay you for an additional E/M service unless you can demonstrate that it is significant and separately identifiable, and that it goes above and beyond the E/M service you would normally provide as a part of the procedure.

Watch out: Some practices define "significant" to mean that the E/M visit with a -25 modifier must be at least a level-four or -five code (such as 99204 or 99215, Office or other outpatient visit for the evaluation and management ...), but the September 1998 CPTAssistant states, "To use modifier -25 correctly, the chosen level of E/M service needs to be supported by adequate documentation for the appropriate level of service. ... modifier -25 is not restricted to any particular level of E/M service."

So you should append modifier -25 to your E/M code if the physician believes that he performed an E/M service that was completely independent of the procedure. "I always say, if you don't have an HEM (history, exam and medical decision-making), you don't have an E/M," says Laureen Jandroep, OTR, CPC, CCS-PCPC-H, CCS, director and senior instructor for the CRN Institute, an online coding certification training center. "There should be clear documentation of the HEM, in addition to any notes about procedures performed."

Tip: To demonstrate that your E/M service qualifies as an independent evaluation, you should physically separate the E/M notes from the procedure documentation in the medical record. The physician should document the HEM in the patient's chart and record the procedure notes on a different sheet attached to the chart. Using this documentation method, a reviewer can clearly identify the two services, each of which you have individually supported with documentation.

Example: Suppose your patient complains of an earache (388.70). The otolaryngologist performs a history and physical and decides to perform nasopharyngoscopy (92511), which reveals a pharyngeal mass (784.2) causing the ear pain.

You should link the E/M visit to the earache diagnosis (388.70, Otalgia, unspecified; earache NOS), and link the nasopharyngoscopy to 784.2 (Swelling, mass, or lump in head and neck).

The requirement that an E/M service must be "separately identifiable" is CMS' attempt to differentiate E/M services included as part of a larger procedure from those that go beyond the usual pre- or postprocedure evaluation and care.

ENT practices sometimes interpret this to mean that you must diagnose a second, distinct condition to bill a separate E/M service, but this is incorrect, says Heather Corcoran, coding manager at CGH Billing Services, a medical billing firm in Louisville, Ky.

Likewise, no requirement dictates that the E/M service must be unrelated to the other service or procedure provided. CPT specifically states, "The E/M service may be prompted by the symptom or condition for which the procedure and/or service was provided. As such, different diagnoses are not required for reporting of the E/M services on the same date." In all cases, though, if a second (related or unrelated) diagnosis is available, you should report it.

Example: Suppose the otolaryngologist sees a patient with a severe nosebleed (784.7, Epistaxis). The otolaryn-gologist obtains the patient's history and performs an otolaryngologic examination. He decides to control the epistaxis endoscopically (31238, Nasal/sinus endoscopy, surgical; with control of nasal hemorrhage).

Because the visit resulted in the decision to control the bleeding endoscopically, some carriers may pay separately for the appropriate E/M code that you report with modifier -25. Others may deny the claim on the basis that the E/M service was incidental to the procedure.

To obtain payment, the otolaryngologist should document -- briefly -- the thought process that led to the decision for endoscopic control of epistaxis. For example, the procedure note could say that because the bleeding was so severe, he required the scope to locate the bleeding and place electrocautery, laser or chemical cautery instruments parallel to the scope to stanch the bleeding.

If, however, the patient has a nosebleed and the otolaryngologist makes a quick assessment, packs the nose and sends the patient home, you should bill only the epistaxis-control code (most likely 30901, Control nasal hemorrhage, anterior, simple [limited cautery and/or packing] any method).

Like modifier -25, you should append modifier -57 (Decision for surgery) to E/M services, but you should not use modifier -57 for minor procedures that you perform with E/M visits. Modifier -57 is appropriate only if, during the patient evaluation, the physician determines that a major surgical procedure (a procedure with a 90-day global period) is necessary and will be performed either that day or the next day.

Although otolaryngologists preschedule most procedures with 90-day global periods, this is not always the case. For example, the otolaryngologist may admit a patient with parotitis to the hospital. Three days later, the patient develops a parotid abscess that requires draining. At that time, the otolaryngologist makes a decision for surgery (to drain the abscess) and indicates it by appending modifier -57 to the hospital care code, which he reports in addition to the surgery.

Self-defense: This lets the carrier know that although the hospital visit that you report is part of the procedure's global period, you can separately report it because the physician made the decision for the surgery during that encounter.

Example: The otolaryngologist evaluates a 15-year-old patient and determines that the patient requires an immediate tonsillectomy because of obstructed breathing. In such cases, you must append modifier -57 to the appropriate-level E/M code that you report with 42821 (Tonsillectomy and adenoidectomy; age 12 or over), which has a 90-day surgical package.

Note: Most carriers follow Medicare's lead and require modifier -57 for major surgeries and modifier -25 for procedures with 10 or zero global days. However, some payers (including some Part B carriers) may have different requirements. Private payers, for example, may require that modifier -57 be appended to all E/M services resulting in the decision for surgery, regardless of the number of days in the global package of the procedure. Always check your payer's guidelines before you bill modifier -57 or -25.