Podiatry Coding & Billing Alert

Find out why the phrase "by the way" offers an effective insight.

Many podiatry practices take modifier 25 as a go-to modifier whenever patients visit for any checkup or procedure, regardless of whether their situation really justified modifier 25. Usually, the intention is to recoup more reimbursement, says John F. Bishop, PA-C, CPC, president and CEO of Bishop & Associates Inc. in Tampa, Fla. As a result, modifier 25 doesn't serve its real function.

Ask these 3 questions, and put the modifier into good use.

1. Does A "BTW" Scenario Take Place?

A very basic hint that tells you your claim might warrant modifier 25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) is to see if the patient had "by the way" (BTW) scenario. This is as good as checking if there was an additional work performed that went above and beyond the typical pre- or postoperative work associated with the procedure code.

Example: Your physician sees a 57-year-old female who's returning to the office under a 10-day global for a postoperative check following a chemical matrixectomy (11730, Avulsion of  nail plate, partial or complete, simple; single). Following an uneventful check-up, the patient tells the podiatrist, "Oh, by the way, I have some heel pain in my other foot now; do you mind checking that out while I'm here?" This signals a situation that calls for an E/M code with modifier 25 is coming up. "Since the patient's checkup is under the global period, you'd code 99024 (Postoperative follow-up visit, normally included in the surgical package, to indicate that an evaluation and management service was performed during a postoperative period for a reason[s] related to the original procedure) for a zero-charge, and for the foot pain checkup, you'd code the appropriate level-one, -two or -three E/M with a modifier 25," Bishop explains.

Tip: You can consider reporting modifier 25 only while coding an E/M service. Otherwise, you should check if the encounter qualifies for modifier 59 (Distinct procedural service).

2. Is The Additional E/M Significant?

Your documentation should support that the extra E/M service provided by the physician is significant and separately identifiable. The physician may not declare a different diagnosis from the diagnosis that supports the needed procedure, and you should always include a documentation of medical necessity in your chart. Make sure you base the use of the modifier on the documentation.

Review: CMS released Transmittal 954 in 2006 (www.cms.hhs.gov/transmittals/downloads/R954cp.pdf) to clarify that you do not need a separate diagnosis for modifier 25 and that payers need not look for documentation of medical necessity unless they suspect a pattern of abuse.

The transmittal also instructs to use modifier 25 when your physician provides a significant and separately identifiable E/M service on the same day as a procedure with a global period. Don't trip over this tricky statement. Some coders mistakenly take this statement to mean that they can't use modifier 25 on a separate E/M service on the same day as a procedure with a zero global.

According to Barbara J. Cobuzzi, MBA, CPC, CPC-H, CPC-P, CHCC, president of CRN Healthcare Solutions, a coding and reimbursement consulting firm in Tinton Falls, N.J., a zero global and an XXX global (no global) are not the same.

Minor procedures with zero global days have a built-in prework component with a history and physical -- that is, a minor E/M, a history, exam and medical decision-making, she says. Thus, you should append modifier 25 to an E/M accompanying a 0-10 global procedure. Do not use it with an E/M accompanying an XXX-global procedure, in which case it's better to just report the services separately.

3. Does The Patient Present For Initial Visit?

Think about this: it is inappropriate to append modifier 25 on a new patient visit because it doesn't affect anything. Your office has never seen this patient before so any procedure performed should not warrant for modifier 25.

Why: You have no established history with the patient to indicate anything was significantly, separately identifiable from the E/M service.

Remember: Modifiers indicate that a procedure was a modified form of its original course. What is there to modify on a new patient if you have no idea what's coming when the patient arrives for the first visit?