Eli's Rehab Report

Coding Insight: Use modifier -25 and proper diagnosis codes to increase your chances for reimbursement.

Offices billing for evaluation and management (E/M) service procedures the same day as trigger point injections dont have to write off the cost of the E/M, says Colette Shelley, the owner of Zebra Resource Management, a medical billing firm in DeSoto, Texas. You can use the modifier -25 with a separate identifier for an E/M service the same day as a starred procedure, such as an injection. Modifier -25 is used to identify a significant, separately identifiable E/M service by the same physician on the same day of the procedure or other service, according to CPT Codes 2000.

But some subscribers maintain they have received confusing advice about modifier -25. At a seminar I attended, we were told that the first procedure billed with the -25 modifier would be paid in full, while the second procedure would be paid at a half rate, an Indiana subscriber says. But that doesnt sound right.

Its not, says Shelley. You need to have documentation of the office visit to show that the patients condition required a service above and beyond the E/M procedure, but neither the E/M nor the injection should be paid at a lower rate, she explains.

New vs. Established Patients

Billers shouldnt have a problem billing an E/M code for a new patient ( CPT 99201 - 99205 ) on the same day as a trigger point injection (20550, injection, tendon sheath, ligament, trigger points or ganglion cyst), says Marie Quattlebaum, biller at the Atlanta Center for Athletes in Atlanta, Ga. If its an initial visit, the doctor is making a decision during his evaluation that the patient requires an injection. But if its a subsequent visit (99211-99215) for the same problem, you cant get paid for both the visit and the injection because its considered a continuation of services. With subsequent visits, we usually charge for the injection but not the E/M code.

Although writing off the E/M charge is not as cost-effective as using modifier -25, it is a common way to bill for E/M codes with injections for established patients. Most billers we polled agree that physicians view billing both the E/M and injection codes as too risky.

Lynn Kelley, office manager at the Boise PM&R Clinic in Boise, Idaho, faces the same coding challenge. When we do an injection with an E/M, we handle it one of two ways: We can either ask the patient to come back another day to receive the injection, or we can bill for the injection and not the evaluation code, she says.

But Kelley notes the doctors have to choose whether to get paid for the visit or the injection in the second example. Typically, if a patient needs an injection, the doctor will choose to do it during the appointment and accept the fact that we may have to write off part of the visit, she explains.

Separate Diagnosis Codes Help Pay Up

Shelley says that separate diagnosis codes can help increase the chances of proper reimbursement when using modifier -25.

For example, an established patient is being seen for water on the knee (719.0, effusion, joint), and during the visit, the doctor discovers tenderness and loss of motion of the thigh (729.1, myalgia and myositis, unspecified) and decides to perform a trigger point injection. The water on the knee would be covered under the E/M code with modifier -25 attached, and the trigger point would be linked to the injection, according to Shelley.

Though separate diagnoses should help reduce denials, the Health Care Financing Administration (HCFA) doesnt necessarily require them when using modifier -25. CPT 2000 states, The E/M service may be prompted by the symptoms or conditions for which the procedure and/or service was provided. As such, different diagnoses are not required for reporting of the E/M services on the same date.

Fred Halbstein, who handles the billing at Comprehensive Pain and Rehabilitation Center in Boynton Beach, Fla., bills the E/M and injection codes on separate line items with modifier -25. Im always careful to make sure that the reports for each CPT code match in case the insurance companies ever need to see them, he says.

The office notes are crucial, adds Shelley. The documentation will always help confirm how the E/M went beyond the usual preoperative or postoperative care associated with the injection.

Note: Refer to page 2 for the new change in the Surgery Guidelines on performance of a starred procedure during initial or established patient visits.