Eli's Rehab Report

Tip: Codes with '000' and 'XXX' classifications are not the same

Just because auditors are targeting modifier 25 doesn't mean you should cut out your use entirely. CMS recently clarified how you should be using modifier 25, which should help payers find a common ground.
 
In a report released in November 2005, the Office of Inspector General recommended to CMS that carriers include reviews of claims containing modifier 25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service). This directive has raised concern in many physiatry practices.

Bottom line: "Every coder should always be concerned and reverent when using modifier 25," says John F. Bishop, PA-C, CPC, president of Bishop & Associates Inc. in Tampa, Fla. "The OIG has really cracked down on this modifier and collected huge sums of money for inappropriate coding." 

Best bet: You should only use modifier 25 when your physiatrist provides a significant and separately identifiable E/M service on the same day as a procedure with a global period. You can read the CMS clarification (implementation date Aug. 20, 2006, but effective date June 1, 2006) at www.cms.hhs.gov/transmittals/downloads/R954CP.pdf.

See whether these common physiatrist scenarios merit using modifier 25.

Study This Same-Day Debridement Example

Scenario 1: A physiatrist sees a patient in his office for neck pain and an infected foot wound. The physiatrist performs an E/M service and then has a staff member use a high-pressure waterjet to selectively debride the small foot wound on the same day.
 
Because the recent CMS clarification states that you should only apply modifier 25 to an E/M code when a procedure performed on the same day has a global period, you should not use the modifier in this situation. The code for the debridement (97597, Removal of devitalized tissue from wound[s], selective debridement, without anesthesia [e.g., high-pressure waterjet with/without suction, sharp selective debridement with scissors, scalpel and forceps], with or without topical application[s], wound assessment, and instruction[s] for ongoing care, may include use of a whirlpool, per session; total wound[s] surface area less than or equal to 20 square centimeters) has a global period of XXX (Global surgical rules do not apply).

Tricky: Procedures that have a 000 global period still have a global period, says Barbara Cobuzzi, MBA, CPC, CPC-H, CPC-P, CHCC, president of CRN Healthcare Solutions, a coding and reimbursement consulting firm in Tinton Falls, N.J. "Minor procedures that have global days of 0 or 10 still have a pre-work component that includes a history and physical and is the equivalent of a minor E/M -- that's why there is a difference between 0 global and no global."

Because the E/M service to see the patient with the cervicalgia and infected wound is significant and separately identifiable, you can still report both the E/M code and 97597. You simply do not need to append modifier 25 to the E/M code (such as 99213, Office or other outpatient visit for the evaluation and management of an established patient ...).

End result: 97597, E/M service (such as 99213).

Check Strapping Code's Global Days

Scenario 2: A patient twists her knee when she falls, and presents to your practice with a badly sprained ankle. Your physiatrist sees the patient for an E/M visit and applies a short leg splint.

When you check the global days for the splint code (29515, Application of short leg splint [calf to foot]), you'll discover that it has 0 global days, but this still means that this procedure has a global period.

In this situation, you should apply a modifier to the E/M office code (such as 99213, Office or other outpatient visit for the evaluation and management of an established patient ).

Heads up: The physician must document "a separate identifiable service above and beyond what is considered inclusive in the procedure," says Sherry Wilkerson, RHIT, CCS, CCS-P, coding/compliance manager at CHAN Healthcare Auditors in St. Louis.

The major conclusion of the OIG study was not that modifier 25 was simply inappropriate. "Medical reviewers found that providers did not document the E/M services and/or procedures for 27 percent (116 out of 431) of the sampled claims received from providers," Wilkerson says.

End result: 29515, 99213 with modifier 25 appended.

Find Out if Injections Mean Modifier 25

Scenario 3: A new patient comes in with complaints of posterior headaches and facial pain. The physiatrist performs a diagnostic supraorbital nerve block to assist with a potential diagnosis of supraorbital neuralgia at the same visit.

You should report 64400 (Injection, anesthetic agent; trigeminal nerve, any division or branch) in addition to the exam code (such as 99201-99205). Because 64400 has a global classification of 000 and therefore has 0 global days,  you should append modifier 25.
Remember: A global classification of "0" still means the code has a global period.

End result: 64400, 99201-99205 with modifier 25 attached.

Want more? Upcoming issues of Physical Medicine & Rehab Coding Alert will feature modifier 25 scenarios that your peers have submitted. Have a modifier mystery you want our experts to solve? E-mail your example to the editor at suzannel@eliresearch.com.

Get more advice by enrolling in The Coding Institute's audioconference "The Scary Truth About Modifier 25 and 59 Misuse: Is Your Practice at Risk?" Find out how misuse has been flagged and make sure your practice is following proper modifier guidelines to stay out of payer scrutiny. Go to http://codinginstitute.com/conference/conference.cgi.