Podiatry Coding & Billing Alert

HEM and OBTW are important acronyms you should remember. What do they mean?

If you're dreading an unwanted visit from your auditor or the Office of Inspector General (OIG), you should begin to pay close attention to your methods of appending modifier 25. Test yourself on the proper application of this modifier with the following scenarios.

Stick to the Basics of History, Exam and Medical Decision-Making

Scenario 1: A podiatrist examines an established patient suffering from pain in her left ankle. The podiatrist performs a full evaluation of the patient, including history, exam and medical decision-making, and decides to take an X-ray.

Consequently, she determines that the patient suffers from Achilles tendonitis (726.71). Based on her workup, the podiatrist decides to give the patient a steroid injection.

Solution: You should report 9923x-25 in addition to 20550 (Injection[s]; single tendon sheath, or ligament, aponeurosis [e.g., plantar "fascia"]) or 20551 (...single tendon origin/ insertion). A key to meeting the basic requirement of modifier 25 is to establish that the service is significant and separately identifiable from the same-day procedure, says Alice G.Beaton, CPC, of Footcare of Hampton Roads in Suffolk, VA.

Technique: One easy way to determine this is by using the 'HEM' test, which basically means the E/M must include a history, exam and medical decision-making. In this case, the physician decides to administer the steroid injection, indicating that it is not a scheduled minor procedure. Basically, modifier 25 tells the carrier that the E/M led to the decision for the minor procedure.

Caution: Before you append modifier 25, make sure that the physician performed a minor procedure, with 0-10 day global period. Otherwise, the modifier would be out of place. Then, once you have concluded that a full and distinct E/M has taken place, you should assign a level of service.

Welcome an "Oh By The Way" Moment

Scenario 2: An established patient who has been diagnosed with cellulitis and abscess of the foot arrives at the office for a prescheduled incision and drainage of a soft tissue abscess on the heel of his left foot. After the procedure, the patient complains that she has also been experiencing pain in the right heel, especially upon rising in the morning. The podiatrist performs a problem-focused history, exam and medical decision-making, and determines that the patient is presenting with plantar fasciitis in the right foot.

Solution: First, you should report 20000 (Incision of soft tissue abscess [e.g., secondary to osteomyelitis]; superficial). Follow it up with the E/M code 99212, plus modifier 25 linked to it. You should declare two diagnoses for this scenario, linking 682.7 (Cellulitis and abscess of foot, except toes) to the procedure and (728.71, Plantar fascial fibromatosis) to the E/M.

This case fits the "oh by the way" (OBTW) requirement of reporting modifier 25. It occurs when a patient is attending one pre-scheduled procedure, but presents with another complaint in a different body part that is unrelated to the current procedure.

Play safe: Separate diagnoses for the procedure and E/M are appropriate in this case although CPT and CMS state that you do not need to have separate diagnoses to append modifier 25.

According to coding experts, having separate documentation for separate diagnoses certainly helps.