Podiatry Coding & Billing Alert

Documentation for additional E/M must be entered in separate section of medical record.

You don't want to miss the latest modifier 25 policy from Pennsylvania's Independence Blue Cross Blue Shield if you work with this payer. Per the information found within the policy, you will now be looking at a 50 percent reduction to claims appended with modifier 25.

Practices Billing This Payer Will See Modifier 25 Pay Slashed by Half

Here's the scoop: Independence will now reimburse claims appended with modifier 25 (Significant, separately identifiable evaluation and management service by the same physician or other qualified health care professional on the same day of the procedure or other service) "at 50 percent of the applicable fee schedule amount" in the following circumstances, the payer said in a May 1 notification:

• When the E/M service is submitted on the same date of service, by the same professional provider or other qualified healthcare provider, as a minor procedure. Note that a minor procedure has a zero-day or 10-day post-operative period.
• When a problem-focused E/M service is submitted on the same date of service, by the same professional provider or other qualified healthcare provider, with a preventive E/M.

In addition, Independence's notification indicates that when you're using modifier 25, "documentation for the additional E/M must be entered in a separate section of the medical record in order to validate the separate and distinct nature of the E/M service." Therefore, it appears that this payer will no longer allow you to document both the E/M and the procedure in the same sentence or paragraph of the note.

Check This Example for Clarity

Consider the following example to illustrate how the Independence policy will impact your podiatry practice.

Example: An established patient comes in for a visit and has a debridement done on his toenails (more than six). The podiatrist then cuts corn and calluses on four toes and also performed skin partial thickness debridement on both feet.

For this scenario, you would report the following:

• The appropriate E/M code (such as 99213,  Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components:...).
• Append modifier 25 (Significant, separately identifiable evaluation and management service by the same physician or other qualified health care professional on the same day of the procedure or other service) to 99213 to demonstrate that the visit was significantly separate from the procedures performed.
• For the nail debridement, report code 11721 (Debridement of nail[s] by any method[s]; 6 or more). Attach modifier Q8 (2 Class B findings) to 11721 to demonstrate the appropriate class findings by the podiatrist.
• For the corn removal, report 11056 (Paring or cutting of benign hyperkeratotic lesion [e.g., corn or callus]; 2 to 4 lesions).
• An ESPU modifier such as XS (Separate structure) with the lesser paying procedure (11721) to differ­entiate this code from 11056.
• For the skin debridement, bill 11042 (Debridement, subcutaneous tissue [includes epidermis and dermis, if performed]; first 20 sq cm or less) for debridement performed up to subcutaneous tissue level (includes epidermis and dermis, if performed); first 20 sq cm or less. In this case, you should not use a bilateral modifier as that is not applicable.

You would normally collect about $74 for the 99213 service, based on the 2017 Medicare Physician Fee Schedule values. However, under the new Independence Blue Cross rules, that number will fall to just $37. Say you report 99213-25 twice a day at your practice - you've now just lost $370 a week or close to $19,240 annually from Independence Blue Cross Blue Shield.

"This policy is absurd," says Barbara J. Cobuzzi, MBA, CPC, CENTC, COC, CPC-P, CPC-I, CPCO,  AAPC Fellow and vice president at Stark Coding & Consulting LLC in Shrewsbury, New Jersey. Although the policy is not a broad CMS directive, it could begin to infiltrate other payers if practices affected by it don't act quickly.

"This could really affect the bottom-line of the practice," says Suzan Hauptman, MPM, CPC, CEMC, CEDC, AAPC Fellow, senior principal of ACE Med Group in Pittsburgh. "The patient's health and convenience are always considered by the providers, but once they start losing money when performing both services on the same day, they will have no other choice but to schedule the patient at a later date for the procedure."

Consider this advice: If you have contracts with Independence Blue Cross Blue Shield, consider approaching your state medical society to see if this policy represents such a radical reinterpretation of contract terms that is not a legally allowable unilateral amendment without the payer getting permission from the state's department of insurance or other regulatory body. Some states have such regulations.

What this could do, according to Hauptman, is burden the patient with a return to the office.

"The physician wants to provide the best healthcare possible to his patients. However, cutting the reimbursement for these surgeries by 50 percent may not cover the expenses to perform them at that time," Hauptman says. "The E/M service that was performed in order to make certain the procedure is the best course of treatment should stand on its own merit when the procedure is performed. Applying the modifier 25 to that visit should clearly illustrate that the both services were performed in their entirety and should be paid accordingly."