Pediatric Coding Alert

Everyone uses modifier -25, but who uses it properly?

Before you attach modifier -25 to a code, do you make sure you have proof that the pediatrician performed a separate and significant service? If you don't, your practice could face long appeals, payment refusals, or worse - audits.
 
In pediatric practices, no modifier is used more often than modifier -25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service), but many pediatric coders aren't clear on how to use -25 appropriately, coding experts say.
 
"The most difficult issue surrounding modifier -25 is ensuring that the E/M service is truly separate and significant from other services the physician furnished on the same date," says Cindy C. Parman, CPC, CPC-H, RCC, co-founder of Coding Strategies Inc., in Dallas, Ga.
 
For instance, the documentation must clearly support that a surgical procedure and the patient evaluation are separate services, and the medical necessity for a separate visit must be clearly stated, she says.

Follow This Lead
 
Here's a scenario that exemplifies the correct use of modifier -25 for a procedure:   An established 4-year-old patient pulls a pitcher off the kitchen counter at her home, causing a bruise and cut on her forearm. The pediatrician sutures the wound and also checks the child for other signs of trauma, performing a level-two E/M exam.  
 
For the repair of the girl's forearm, report 12001 (Simple repair of superficial wounds of scalp, neck, axillae, external genitalia, trunk and/or other extremities [including hands and feet]; 2.5 cm or less). Report the E/M exam CPT 99212 (Office or other outpatient visit for the evaluation and management of an established patient, which requires at least two of these three key components: a problem-focused history, a problem-focused examination, and straightforward medical decision making) and append modifier -25 to show that the laceration repair was separate from the E/M service.
 
You would use modifier -25 in this situation because the E/M exam is unrelated to the laceration repair, coding experts say. The accident caused the laceration, but the pediatrician didn't need to perform the E/M exam to determine that; she had to perform the E/M exam to make sure the accident didn't cause the child any other injuries.
 
If your documentation clearly supports two separately identifiable services, you can use modifier -25.

Learn 4 Carrier Guidelines

Payers vary on the acceptable uses of modifier -25, so you should keep updated on relevant requirements. Many private carriers and HMOs accept modifier -25 when:

 1. one problem, finding or complaint prompts both an E/M service and a minor surgical procedure
 2. counseling and coordination of care occur on the same day, usually after a minor surgical procedure.
 3. there are two co-existing unrelated and separate problems, one evaluated by an E/M service and the other evaluated or treated by a minor surgical procedure.
 4. a preventive medicine visit occurs when the physician addresses a significant, separately identified problem.

Careful: The Feds Are Watching

As if modifier -25 didn't present enough challenges on its own, pediatric practices will have to deal with government scrutiny as well.
 
In 2003, the Department of Health and Human Services instructed its Office of the Inspector General (OIG) to assess the "adequacy of controls to identify physicians with aberrant coding patterns, specifically coding disproportionately high volumes of high-level evaluation and management codes that result in greater Medicare reimbursement."
 
In other words, doctor's offices misusing modifier -25 and similar codes were in the crosshairs of OIG investigators for most of last year. Claims with modifier -25 are certainly getting more government scrutiny, says Lisa Clifford, CPC, of Clifford Medical Billing Specialties in Naples, Fla. "I can see why they're doing it," she says of the OIG's recent crackdown. "The problem is many [doctors' offices] are interpreting modifier -25 too loosely."
  
In order to avoid the red tape of appeals and the eye of the OIG, Clifford stresses correct use of modifier -25 - for herself and her colleagues. "I preach to my doctors consistently," she says. "I always ask them: 'What did you see the patient for today?' "
 
If it's not separately identifiable from another pro-cedure performed on the same day, she advises against using modifier -25. Payers want to see some written proof of separately identifiable services, so make sure no claim using modifier -25 goes out without the appropriate (and separate) documentation of each service, she says.