Pediatric Coding Alert

Find out if you have what it takes to be a modifier master.

Once you’ve answered the quiz questions on page 59, compare your answers with the ones provided below.

Answer 1:
CPT^® defines modifier functions as:

• Providing “the means to report or indicate that a service or procedure that has been performed has been altered by some specific circumstance but not changed in its definition or code,” and
• Enabling “health care professionals to effectively respond to payment policy requirements established by other entities.”

In other words, modifiers allow you to indicate when circumstances require a provider to change a service or procedure described by a specific CPT® code without changing the underlying code itself. This, in turn, enables payers to determine what the provider did and how, or even if, they should pay for that particular service.

Answer 2:
If you read the modifier’s descriptor closely, you can begin to see some of the problems you can encounter when using it. Simply put, if the procedure or other service is not on the same day, if the evaluation and management (E/M) service is not significant or separate from the procedure, and if the same physician or qualified healthcare professional (QHP) did not perform both the E/M service and the procedure (or if either service was performed by someone other than a physician or QHP), then you have incorrectly applied the modifier.

Answer 3:
“Billing a separate E/M service with modifier 25 in this scenario would not be appropriate,” explains Mary I. Falbo, MBA, CPC, CEO of Millennium Healthcare Consulting Inc. in Lansdale, Pennsylvania. “This is because the lesion removal was the sole reason the patient came to the office. The provider did not perform a significant or separately identifiable E/M service, so you cannot charge for it.”

Coding caution: Procedure 11401 has a 10-day global, so if your provider were to perform a separate E/M service along with the procedure, you would be correct in appending modifier 25 to the E/M service, as it should only be used on E/M services performed with minor procedures that have a 0- or 10-day global period. E/Ms along with procedures with a 90-day global period will typically take modifier 57 (Decision for surgery).

Answer 4:
“Identifying the patient’s immunization status, and evaluating the possibility of a fracture and possible concussion, even though they are ruled out, mean that your provider performed separate and additional work to the laceration repair,” says Marcella Bucknam, CPC, CCS-P, COC, CCS, CPC-P, CPC-I, CCC, COBGC, revenue cycle analyst with Klickitat Valley Health in Goldendale, Washington. “This means you can bill an E/M service separately using modifier 25.”

Coding tip: use a different diagnosis code for the visit versus the laceration repair, as payers may only pay for the procedure and include the visit in with the procedure.

The Bottom Line

Before you submit any more claims featuring modifier 25, “you should ask yourself the four following questions,” says Falbo:

• Was the procedure or service unscheduled?
• Did the E/M service uncover signs and symptoms in the patient that the provider must address with a procedure or service?
• Did the provider address more than one diagnosis?
• Did the provider perform work that went above and beyond normal preoperative and postoperative work?

“Answer ‘yes’ to any of them, and there’s a good chance that an E/M service with modifier 25 appended will be seen as medically necessary providing you have the documentation to support it,” Falbo concludes.