Otolaryngology Coding Alert

Answer: You need to place a -25 modifier on the evaluation and management (E/M) code if the doctor is performing and documenting significant and separately identifiable E/M services over and above the control of the hemorrhage.

According to CPT, there is no difference between new or established patients on the payment and coding rules for attaching the -25 modifier to E/M services. But more and more payers are denying E/M and scopes, says Barbara Cobuzzi, CPC, CPC-H, an independent coding and reimbursement specialist in Lakewood, N.J.

I find I can justify the modifier -25 payment for new patients easier than for established patients, as I am showing that the doctor knew nothing of this patient and had to work them up to determine what to do. This is the case with established patients too, but it doesnt float on appeals as often because of the unilateral decision-making and changes to coding rules that payers make.

To show a significant, separately identifiable service by attaching modifier -25 to the appropriate E/M code, the physician needs to document history, exam and medical decision-making and also write a procedure note. Even if the procedure is diagnostic in nature, it must be documented separately from the E/M exam to help support the modifier -25 E/M appeal, Cobuzzi says.

Susan Callaway-Stradley, CPC, CCS-P, an independent coding consultant and educator in North Augusta, S.C., adds, Carriers usually will not reimburse a separate E/M for essentially stopping a nosebleed unless it is for a new patient who arrives complaining of chronic nosebleeds. Some carriers may pay the E/M, but that does not mean it was correct. And if the coding is audited, the payment may have to be returned.

If the E/M was a separate and significant service, an office or other outpatient E/M code (99211-99215) should be billed with a -25 modifier attached, along with the codes for the procedure itself (30901, 30903 or 30905).