Pediatric Coding Alert

Tighten your documentation before you append, experts say

Insurers will cast a spotlight on the use of modifiers 59 and 25 this year, and they are just waiting for your pediatric practice to make mistakes. If you want to stay off the radar screen, documentation for your modifier 59 and 25 claims will be key.

The U.S. Department of Health and Human Services’ Office of Inspector General (OIG) recently found a 35 percent error rate for modifier 25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) and a 40 percent error rate for modifier 59 (Distinct procedural service) in a sample of claims. Experts warn that private payers are sure to follow the OIG’s lead in scrutinizing claims that bear these modifiers, which could affect your pediatric practice.

“The good news is that most pediatric practices aren’t subject to OIG audits in the same way that specialists with high Medicare patient rates are,” says Heather Corcoran, coding manager at CGH Billing Services in Louisville, Ky. “The bad news is that private payers frequently follow the OIG’s lead and start auditing the same claims that the OIG audits.”

To protect payment for your modifier use, follow our experts’ tips.

Confirm Documentation Before Using 59

To ensure that you’ve been appending modifier 59 properly, pull a sample of your modifier 59 submissions and verify that the claims properly represent distinct procedural services.

One way: Make sure the physician is working in a separate body area before you use modifier 59, says Margie Scalley Vaught, CPC, CPC-H, PCE, CCS-P, MCS-P, a coding consultant in Ellensburg, Wash.

Or if the physician performs more than one procedure on the same site, you should be able to prove the medical necessity of both procedures. You should also make sure you use separate ICD9 Codes for the diagnoses behind the separate procedures whenever possible, Vaught says.

Put 59 on the Secondary Code
 
You should always append modifier 59 to the secondary code. The National Correct Coding Initiative publishes a “list of mutually exclusive codes that contains edits consisting of two codes (procedures) that cannot reasonably be performed together based on the code definitions or anatomic considerations,” says Laurie Green, CPC, coding and compliance analyst at Group Health Cooperative in Seattle. Each edit consists of a column 1 code (which is the primary procedure) and column 2 code (the comprehensive, or bundled, code).

How bundles work: Suppose your payer, such as Medicaid or Blue Cross, follows NCCI edits. If a pediatrician reports the two codes for the same beneficiary for the same date of service without an appropriate modifier, the insurer pays only the column 1 code, Green says. The insurer may allow payment for both codes if clinical circumstances justify appending a modifier to the column 2 code of a code pair edit.

Suppose your pediatrician performs both nebulizer treatment and training on the same date of service. You report 94640-59 (Pressurized or nonpressurized inhalation treatment for acute airway obstruction or for sputum induction for diagnostic purposes [e.g., with an aerosol generator, nebulizer, metered dose inhaler or intermittent positive pressure breathing (IPPB) device]) and 94664 (Demonstration and/or evaluation of patient utilization of an aerosol generator, nebulizer, metered dose inhaler or IPPB device), but your insurer denies the claim.

The error? The claim incorrectly appends modifier 59 to the comprehensive or column 1 code (94640) instead of the component or column 2 code (94664). Action: If you notice that you have put modifier 59 on the wrong code, resubmit the claim. In the event of an audit, payers should look positively on your proactive stance.

Reserve 25 for Separate Evaluation Service

Another documentation problem area involves modifier 25, but the modifier’s descriptor of a significant, separately identifiable E/M service isn’t at the root of most of the claim problems. The OIG found that some 27 percent of modifier 25 claims had documentation of the procedure but not the separate E/M.

Best bet: When using modifier 25, you should remember the maxim “If you don’t have a HEM, you can’t bill an E/M,” says Laureen Jandroep, OTR, CPC, CCS-P, CPC-H, CCS, director and senior instructor for CRN Institute in Absecon, N.J.

Here, “HEM” stands for “history, exam and medical decision-making.” All procedures include some service related to patient evaluation and management, but a separate E/M should include its own HEM, Jandroep says.

Example: A patient presents with a laceration to her hand. You perform an evaluation and discover that the patient also has otitis media (OM).

Because the OM E/M is unrelated to the laceration repair, you should report the laceration repair code (such as 12001, Simple repair of superficial wounds of scalp, neck, axillae, external genitalia, trunk, and/or extremities [including hands and feet]; 2.5 cm or less) linked to 882.0 (Open wound of hand except finger[s] alone; without mention of complication).

In addition, report the appropriate E/M code with modifier 25 appended, and link it to the OM diagnosis, such as 382.00 (Acute suppurative otitis media without spontaneous rupture of ear drum).