Pediatric Coding Alert

Solid chart note and payer's rule will help you win payment

What should you do when a payer sends you an E/M rejection with a procedure or service claim?

Should you:
 a. look at your documentation?
 b. check the insurer's policy?
 c. contact the payer's medical director?
 d. appeal citing HIPAA and CPT rules?

Actually, coding experts recommend you do all four. Here's why:

1. Verify Encounter Meets Modifier -25 Criteria

You should first check that your chart note supports billing the E/M with modifier -25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service). "Every procedure has a small E/M built into it," says Kay Faught, coding consultant for CPT Coding and Clinic Management in Jacksonville, Ore. So you must show that you performed a significant, separate service from the procedure or other service.

Example: You give a patient a shot in the arm, such as 95115 (Professional services for allergen immunotherapy not including provision of allergenic extracts; single injection). "The procedure has a little bit of evaluation in it," Faught says. To also code an E/M, for instance 99212-99215 (Office or other outpatient visit for the evaluation and management of an established patient ...), you must document a history, evaluation and medical decision-making apart from that included in the injection.

Tip: If your chart note's E/M documentation can stand on its own, fight for modifier -25 pay, if no carrier policies disallow the particular code combination, such as a same diagnosis E/M with allergen immunotherapy. You don't have to write the notes on a separate sheet, but visually separating the services or service and procedure will help show you whether the E/M "meets the test of water," says Victoria S. Jackson, CEO of Southern Orange County Pediatric Association with 11 pediatric offices in California.

Example: If you're coding an office visit in addition to a preventive medicine service (99381-99397), enter each service in a different box or template. To code the modifier -25 service, the office visit must contain a history, evaluation and treatment, Jackson says. "If no treatment exists, such as with a rash, you can't code the separate E/M."

2. Read the Payer's Rules

Some insurers will not pay for an E/M service in addition to certain procedures or other E/M codes, regardless of your documentation. And if your contract specifies these restrictions, you shouldn't waste time appealing the decision.

Better method: Know your payers' rules. If your contract includes rules that require you to report services differently from CPT guidelines, you must follow them. But make sure to address these variations when your contract comes up for renewal.
 
Payer bundles "vary across the country," Faught says. Midwest insurers don't impose too many modifier -25 restrictions, she says.

Other insurance companies may require additional criteria. For instance, Louisiana Medicaid will not pay for an E/M service with a procedure, unless the codes contain different diagnoses, says Brian A. Audler, CPC, president of CodingandEducation.com in New Orleans. All other insurers in his region pay.

Thomas Riney with Pediatric Associates in Gulf View, Fla., however, reports problems with numerous insurers, including "Tricare, Medicaid and most others."

3. Involve Others in Across-the-Board Rejections

But how do you know when a payer's denials have gone from contract-approved denials to inappropriate activity? "If an insurer never pays a modifier -25 service, you should find out why," Faught says. Insurers should recognize that a physician may sometimes have to provide a separate service.

If a payer consistently rejects modifier -25 claims, raise the ante. "Talk to the medical director," and involve your local medical board, Faught says.

Other sources: Inform your state pediatric-council chapter of the problem - not all states have these. You can also get support from the American Academy of Pediatrics Division of Health Care Finance and Practice at "AAP Coding Hotline" at www.aap.org.

4. Appeal With Regulation, Documentation

When you appeal a modifier -25 decision, remind the insurer of two facts:

1. HIPAA requires that government and third-party payers use ICD-9 and CPT as the official code set. Because CPT clearly defines the appropriate use of modifier -25, the insurer must accept the modifier.

2. You have submitted the claim based on documentation that supports using modifier -25. Include a copy of CPT's "Appendix A - Modifiers" description of modifier -25 along with a standard form letter.

Bonus: Get a copy of Jackson's tried-and-true modifier -25 appeal letter that you can send with every dual-service appeal. Simply send an e-mail to jgodreau@medville.com for your free template.