Pain Management Coding Alert

Remember Medicare has certain criteria to meet. 

It’s not unusual for a pain management specialist to conduct an E/M visit and administer an injection on the same day. If you’ll be filing the claim with Medicare, don’t assume that appending modifier 25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) is a fail-safe for reimbursement. Pay attention to three specific areas on the claim to boost your success. 

• Check the level of service. The visit you’re coding as an E/M service must be for reasons other than a simple 5-minute or less pre-op service or facility required H&P that is assumed to be included in any visit. Help determine the level of service by asking yourself questions such as: 

1. Did the physician evaluate the patient for a new prescription or re-evaluate him to renew an old one?
2. Did the physician address a new problem that the patient reported during that session?
3. Did the physician order tests or schedule other procedures for later that day to treat another known problem? 

Those types of situations help support modifier 25 and a separate E/M code. 

• Check all the diagnoses. You must have a separate, identifiable reason for the E/M service supporting the procedure that the physician performed that day. Neither CPT® nor Medicare requires you to have a separate diagnosis for reporting modifier 25, but it can be helpful because it helps the insurer better understand the situation. Did the doctor perform facet blocks (64490-64495, Injection[s], diagnostic or therapeutic agent, paravertebral facet [zygapophyseal] joint [or nerves innervating that joint] with image guidance [fluoroscopy or CT] …) and write a prescription for the patient’s difficulty with sleeping? If so, report both of the correct diagnosis codes: 721.x (Spondylosis …) for the patient’s spondylosis and 780.52 (Insomnia, unspecified) for the insomnia evaluation. 

• Check the reports. Before you submit your claim with modifier 25, be sure the physician writes separate reports for the procedure (the operative report) and the E/M visit (the follow-up notes). They might sometimes complain about the extra paperwork, but they should be willing to cooperate when they realize how it affects their bottom line.

Final tip: Remember to pair modifier 25 with the E/M code, not the code for the injection or other service the physician performed.