Part B Insider (Multispecialty) Coding Alert

Plus: Modifiers 58 and 78 on the slate for clarification

When a patient comes in with a set of symptoms for the physician to diagnose before deciding to perform a procedure on the same date, can the physician use the modifier 25 to garner separate E/M pay?

This "gray area" has caused some confusion for coders and coding experts, several of whom want to be able to use the 25 modifier when the physician does significant extra work diagnosing the patient.

Coding experts cite the following scenario: A patient presents with knee pain that could be due to a number of causes. The physician finally narrows it down to fluid in the joint, and performs an arthrocentesis. Because the physician had to examine and diagnose the patient, he wants to append modifier 25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) to the E/M code and also report the arthrocentesis code.

According to many coders, however, the physician can't. Their rationale: Confusing wording in a book published by the American Medical Association called Coding With Modifiers seemed to argue that you couldn't use the 25 modifier except in the case where the E/M was completely unrelated to the minor procedure (see PBI, Vol. 6, No. 17).

In a situation with a related E/M before a procedure, you should be able to bill for the E/M visit separately from the procedure, but you shouldn't use the 25 modifier, argues Tracy Gordy, a physician who chairs the AMA's CPT Editorial Panel. In the knee pain example, you would bill for the E/M as well as the fluid removal, but you wouldn't attach a modifier unless your local carrier's policies specifically require one, Gordy adds. You should contact your carrier to find out its local policy, he suggests.

The classic case for the 25 modifier is a situation where a patient comes in to the hospital for tests and has to stay overnight, then the patient falls out of bed and needs to be examined for a fractured hip, says Gordy. "It's when you have already done something, but then you have a reason to come back and do something different." He believes the 25 modifier usually should be used for E/M after a procedure, not before.

Most payors won't pay for an E/M directly before a related procedure, no matter what modifier you use, says consultant Deborah Grider with Medical Professionals in Indianapolis, who wrote Coding With Modifiers. She believes that you should be able to bill for a related E/M along with a minor procedure in some situations, but unfortunately no payor will accept it.

AMA May Explain Some Modifiers

The AMA receives a lot of questions about modifiers, including the 25 modifier and the 21 modifier, for prolonged services, Gordy says. The Association may soon issue some clarifications on several of these modifiers, possibly in the form of one or more articles in CPT Assistant.

Providers also have some confusion with the 58 (staged procedure) and 78 (return to the operating room for a related procedure) modifiers, and the CPT Panel has been talking about this issue. The Panel is trying to come up with more examples to help coders understand which of these modifiers to use in different situations.

Gordy offers an example of the difference between a staged procedure and a return to the operating room for a related procedure:

Staged Procedure: A physician is doing a procedure on a burn patient, and decides that the patient must come back to the operating room for two more sessions of debridement or skin grafts. This would be a staged procedure, Gordy says.

Return to the OR: But if the patient has the three scheduled sessions of grafts or debridement and the physician decides on the third session that the patient will need two more sessions, then you'd use the 78 modifier for a return to the operating room. For the first three sessions, "you plan it, they're staged, and then on that third visit, you realize I'm not there, so you have to return them," Gordy explains. "So you have to clarify why you're returning them."