Podiatry Coding & Billing Alert

Hint: Never mix up modifiers 25 and 57 on your claims.

Your podiatry practice must know how to append commonly used evaluation and management (E/M) modifiers properly or your MAC could ask for a refund. Take this coding challenge to see how your modifier know-how measures up to avoid modifier errors that could land your claims on your MAC's hot list.

If E/M Service Related to Original Surgery, Don't Append Modifier 24

Question 1: Can you append modifier 24 if the E/M service is related to the original surgery such as a complication or infection?

Answer 1:  No. You cannot bill separately for E/M-related services relating to the original surgery during the global period. A surgical complication or infection is considered part of the surgery package. When you append modifier 24 (Unrelated evaluation and management service by the same physician or other qualified health care professional during a postoperative period), you are telling the payer that the surgeon is seeing the patient for a problem unrelated to surgery. Therefore, the medical record must support that the E/M visit was unrelated to the postoperative care, and the diagnosis should clearly indicate the reason for the unrelated postoperative encounter.

Some third-party payers will consider services provided for some complications. Touch base with them before submitting the claim.

Bottom line: You should only attach modifier 24 to an appropriate E/M code when the physician renders the E/M service during a 10 or 90-day postoperative global period for reasons unrelated to the patient's surgery. Also, modifier 24 only applies to services your physician performs after the surgical procedure.

Coding solution: The podiatrist sees an established patient in the office for an ingrown toenail of the right first toe medial border, and he surgically removes a section of the toenail. There is a 10-day global on this procedure.

The patient returns a week later for surgical follow-up, and there is appropriate healing of the toenail with no complication, but the patient now complains of pain in the left heel. The podiatrist performs a workup, orders X-rays, and diagnoses the patient with plantar fasciitis. The podiatrist treats the patient with a prescription for an anti-inflammatory and gives him a referral for physical therapy. This service would now allow for an E/M visit with the use of modifier 24, and you would report 99213 (Office or other outpatient visit for the evaluation and management of an established patient...)-LT-24.

Not Sure When to Append Modifier 25? Read This

Question 2: Can we append modifier 25 to indicate a distinct E/M with a major procedure performed on the same day?

Answer 2: No. You should only 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 indicate a distinct E/M with a minor procedure (zero or 10-day global period) performed on the same day.

When you append modifier 25, make sure to follow the following rules:

• 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.
• The E/M service must occur on the same calendar day as the original procedure, for the same patient.
• The procedure following the E/M would be a minor procedure, meaning that it has a zero or 10-day global period. For 90-day procedures, you would instead use modifier 57 (Decision for surgery) on the E/M service.

Coding solution: The podiatrist saw an established patient who complained of ankle pain in his right foot after falling and twisting his foot in the shower. The podiatrist performed a level-two E/M and diagnosed the patient with a sprained ankle. The podiatrist then applied a splint to the patient's sprained ankle.

You would report the following codes, in this case:

• 29515 (Application of short leg splint (calf to foot))
• S93.401A (Sprain of unspecified ligament of right ankle, initial encounter) as the diagnosis code to support the splinting code
• W18.2XXA (Fall in (into) shower or empty bathtub, initial encounter) linked to the splinting code to show the cause for injury
• 99212-25 (Office or other outpatient visit for the evaluation and management of an established patient...) to report the level-two E/M service. Note: You should attach modifier 25 to 99212 to support separately billing the E/M service.
• 99070 (Supplies and materials (except spectacles), provided by the physician or other qualified health care professional over and above those usually included with the office visit or other services rendered (list drugs, trays, supplies, or materials provided)) or A4570 (Splint) for the splint, depending upon the payer's preference for supply coding.

Identify Physician's Decision to Perform Surgery for Correct Modifier 57 Use

Question 3:  How does the physician's decision to perform surgery impact your modifier 57 use?

Answer 3: According to the CPT^® manual, 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, explains Melanie Witt, RN, MA, an independent coding expert based in Guadalupita, New Mexico.

Caution: 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," Witt says.

Catherine Brink, BS, CMM, CPC, president of Healthcare Resource Management in Spring Lake, New Jersey, emphasizes the importance of understanding modifier 57's definition. "You add modifier 57 to the appropriate level of E/M service provided on the day before or day of surgery, in which the initial decision is made to perform major surgery," Brink says.

Remember: You should consider only using modifier 57 with an E/M on the day before or the day of a major surgical procedure, never a minor surgical procedure, according to Brink.