Podiatry Coding & Billing Alert

Hint: Only append modifier 25 to E/M codes.

CPT^® modifiers can be tricky to learn because there are very specific instances in which you should append these modifiers. But your claims don’t have to fall under scrutiny.

Answer the following questions about commonly-used modifiers you can append to CPT^® codes to make sure your podiatry claims stay in tip-top shape.

Don’t miss: You can find all of these modifiers in Appendix A of the CPT^® manual.

Grasp Essential Modifier 25 Rules

FAQ 1: Can you 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 any CPT^® code?

Answer 1: No. You should only apply modifier 25 to evaluation and management (E/M) codes.

You can apply modifier 25 to an E/M service that is separate and significant from another procedure or service at the same encounter, explains Melanie Witt, RN, MA, an independent coding expert based in Guadalupita, New Mexico. “The note must clearly indicate that the E/M dealt with issues that were not part of the other services,” she continues.

When you use modifier 25, it indicates that “on the day of a procedure, the patient’s condition required a significant, separately identifiable E/M service, above and beyond the usual pre- and postoperative care associated with the [other] procedure or service,” adds Mary I. Falbo, MBA, CPC, CEO of Millennium Healthcare Consulting, Inc. in Lansdale, Pennsylvania.

Modifier 25 is one of the most misunderstood modifiers, so make sure you follow these rules:

• Rule 1: You can only append modifier 25 to E/M service codes 99201 (Office or other outpatient visit for the evaluation and management of a new patient, which requires these 3 components ...) through 99499 (Unlisted evaluation and management service).
• Rule 2: You may use modifier 25 only when your provider’s documentation proves that he performed a medically necessary and “significant, separately identifiable” E/M service in addition to the original procedure. Your physician must include a separate History, Examination, and Medical-decision making (HEM) for the E/M service in his documentation.
• Rule 3: The E/M service must occur on the same calendar day as the original procedure for the same patient.
• Rule 4: The procedure following the E/M would be a minor procedure, meaning that it has a zero or 10-day global period.

Coding example: An established patient came into the podiatrist’s office complaining of corns and calluses. The podiatrist performed an expanded problem focused history, an expanded problem focused exam, and he used low complexity medical decision making. The podiatrist spent about 15 minutes with the patient. The podiatrist then pared four corns — one on the bottom of the patient’s foot and three on her toes. The tissue was benign.

Coding solution:  You should report the following codes:

• 11056 (Paring or cutting of benign hyperkeratotic lesion (eg, corn or callus); 2 to 4 lesions) since the podiatrist pared four lesions.
• 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: an expanded problem focused history; an expanded problem focused examination; medical decision making of low complexity…) for the E/M service.
• 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 the 99213 service to show that the E/M was significant and separately identifiable from the corn parings.

Analyze Modifier 53 With Coding Scenario

FAQ 2: I’m new to podiatry and was wondering if you could you explain how to appropriately append modifier 53?

Answer 2: You should append modifier 53 (Discontinued procedure) to indicate that discontinuing the procedure was necessary to protect the patient’s health.

“Due to extenuating circumstances or those that threaten the wellbeing of the patient, it may be necessary to indicate that a surgical or diagnostic procedure was started but discontinued,” according to the CPT^® manual. “This circumstance may be reported by adding modifier 53 to the code reported by the individual for the discontinued procedure.”

Take a look at the following coding example to give you an idea about how to correctly append modifier 53.

Coding example: The podiatrist began a screw removal on an in-patient in the hospital. However, the podiatrist had to discontinue the surgery because the patient’s health became endangered.

Coding solution: You should report 20680 (Removal of implant; deep (eg, buried wire, pin, screw, metal band, nail, rod or plate)) for this service and append modifier 53 to show the podiatrist discontinued the procedure to protect the patient’s health.

Always submit documentation: Submitting modifier 53 alone does not provide the payer with enough information to know how to correctly reimburse the provider. So, make sure you submit the supporting documentation for appending modifier 53. The documentation must state that the physician actually started the procedure, why it was medically necessary for him to discontinue the procedure, and what percentage of the procedure he did perform.

Strengthen Your Modifier 57 Skills

FAQ 3: How does the physician’s decision to perform surgery relate to modifier 57 use?

Answer 3: The CPT^®  manual specifically states you should use modifier 57 (Decision for surgery) when an E/M service results in the physician’s initial decision to perform the surgery.

Important: The E/M service must occur on the same day of or the day before the surgical procedure. Using modifier 57 lets the provider receive credit for the additional work required to make the decision to do major surgery on the day of or day before that surgery.

Don’t miss: You should append modifier 57 only when the surgery is major, which means it has a 90-day global surgery period.

Caution: However, you should never report modifier 57 for an E/M service the day of or day before a preplanned or scheduled major (90-day) surgical procedure. If the decision to do surgery is made before this time period, no modifier 57 is reported for the E/M service as all major procedures include preoperative clearance the day of or the day before surgery.