Eli's Rehab Report

Do you know when an RVU includes an evaluation? Here's the answer

If you don't know the how-to's of coding with modifier 25, you could be facing something much more costly than a denied claim.

The Office of Inspector General (OIG) has taken a special interest in this modifier, but careful attention to appending modifier 25 could prevent an unwanted visit from your auditor.

Learn to Jive With Modifier 25

When your physiatrist performs a procedure on the same date as a distinct E/M service (such as CPT 99201 - 99205 for a new patient or 99211-99215 for an established patient), you'll most likely look to modifier 25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) to help your payer process the E/M code correctly.

Example: An established patient presents to see the physiatrist. The physician examines the patient, orders a diagnostic x-ray, writes a prescription for an anti-inflammatory medication, orders eight sessions of physical therapy and decides to administer a trigger point injection.

For this visit, you would report 20552 (Injection[s]; single or multiple trigger point[s], one or two muscle[s]) and the appropriate-level E/M code (99211-99215). You would also attach modifier 25 to indicate that the E/M portion of the visit was separate and distinct from the procedure (the trigger point injection).

Take This Test

Read the following three visit notes and decide where to use modifier 25. Check the answers to see if you've got modifier 25 down pat.

First visit: Your physiatrist sees a patient for the first time. After the initial evaluation, the physician decides to administer a series of epidural steroid injections over a period of time. The receptionist schedules the patient for the first injection a week later. Should you add modifier 25 to the E/M code?

The answer is no. The physiatrist did not perform a procedure on the same day as the E/M service. Consequently, you should report only a new patient office visit (99201-99205).

Second visit: The patient comes for the injection. The physiatrist spends a few minutes talking to the patient before performing the epidural procedure (62311, Injection, single [not via indwelling catheter], not including neurolytic substances, with or without contrast [for either localization or epidurography], of diagnostic or therapeutic substance[s] [including anesthetic, antispasmodic, opioid, steroid, other solution], epidural or subarachnoid; lumbar, sacral [caudal]). Should you add  modifier 25 to the E/M code?

Although the physiatrist performed the epidural procedure, the answer is no. "You should just bill for the injection and not an E/M code because [the relative value unit for the procedure includes the suitable preoperative and postoperative evaluation and] usually you cannot report pre- and postoperative time with the patient," says Murthy Cherala, president and CEO of MC Business Solutions Inc. in Elgin, Ill. 

Third visit: The patient arrives for the third round of the lumbar epidural injections. During this visit, she tells the physiatrist that she's improving on pain, but she's also experiencing numbness in the lower part of her body. She says she also has tingling that wasn't there before. The physiatrist evaluates the patient and orders additional diagnostic testing, such as an electromyography or nerve conduction study, and modifies current therapies or prescriptions before proceeding with the injection. Should you add modifier 25 to the E/M code?

The answer is yes. The physiatrist is evaluating a separate problem as well as administering the lumber epidural injection, so you should report the injection code (62311) and apply modifier 25 to your E/M code (99211-99215). Be sure to link the E/M code to the new symptom diagnosis (782.0, Disturbance of skin sensation).

Consult Codes Count

Don't overlook applying modifier 25 to consultation codes. "We most often report modifier 25 when a patient comes in for a new consultation with the physician (99241-99245), and the physician makes the decision to provide an office injection for pain relief," says Kay Brown, CPC, a coder at Bayou Revenue Management in Spring, Texas.