Practice Management Alert

The HHS Office of Inspector General placed modifier 25 on its hit list again this year, which means you need to be extra vigilant when using this modifier to secure reimbursement for same-day E/M services.

Follow these three steps to learn when - and when not - to use the modifier, and how to win an appeal if a carrier denies your claim.

1. Know the Right Times to Report Injections and E/Ms

In some circumstances, you can bill for both an injection and an office visit even though Medicare bundles these services.
 
For instance, suppose a new patient presents to receive a steroid injection for shoulder pain, but the patient also has hypertension. You would bill for the injection and for the evaluation and exam of the hypertension, says April Borgstedt, CPC, president of Working for You Consulting in Broken Arrow, Okla.

You code: For the injection, you could report G0351 (Therapeutic or diagnostic injection [specify substance or drug]; subcutaneous or intramuscular) along with the appropriate E/M, such as 99203 (Office or other outpatient visit for the E/M of a new patient ...). Be sure you attach modifier 25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) to the E/M code to show it's a separate service, Borgstedt says.

If your office is billing a private carrier, you may have to use CPT injection code 90782 (Therapeutic, prophylactic or diagnostic injection [specify material injected]; subcutaneous or intramuscular). Remember that Medicare no longer accepts this code. Ask your private payer for its injection and modifier 25 policies.

2. Check Your ICD-9 Codes

Before you separate out the E/M with modifier 25, be sure the physician performed an exam that will satisfy coding and medical-necessity guidelines, Borgstedt says. For example, if the patient is new to your office, your physician's E/M service should meet all three key elements: history, exam and medical decision-making.

In addition, link the appropriate ICD-9 codes to the procedures and E/M. For instance, in the example above you would tie the patient's shoulder pain diagnosis code 729.5 (Pain in limb) to G0351, and the hypertension code (such as 401.1, Essential hypertension; benign) to the E/M code.

Heads-up: Coding guidelines and insurers' policies may not require different diagnosis codes for the procedure and E/M when you use modifier 25, but if the physician's documentation merits separate ICD-9 codes, this may increase your chances of getting paid with some carriers, Borgstedt says.

Watch out: Private insurers often require a separate condition or reason for the E/M service. But make sure you don't artificially come up with diagnosis codes to support the separate E/M charge, says Marcella Bucknam, CPC, CCS, CPC-H, CCS-P, HIM program coordinator at Clarkson College in Omaha, Neb. The medical documentation should always support what the physician bills and the codes you use, she says.

3. Be Aware of Payer Differences on Ancillary Services

When your physician performs an office visit and then also provides an ancillary service, such as a chest x-ray or lab test, to determine a diagnosis or the treatment plan, you typically don't need to use modifier 25 to separate the E/M service, Borgstedt says.

Example: Along with an exam, your physician performs a urinalysis, which is an ancillary service, for a patient with suspected diabetes. In this case, you could report the appropriate E/M code (such as 99212, Office or other outpatient visit for the E/M of an established patient ...) along with 81002 (Urinalysis, by dip stick or tablet reagent for bilirubin, glucose, hemoglobin, ketones, leukocytes, nitrite, pH, protein, specific gravity, urobilinogen, any number of these constituents; non-automated, without microscopy) without using modifier 25.

Quick tip: Not all private insurance companies follow CPT coding guidelines, Bucknam says. This means a carrier may require you to attach modifier 25 to any E/M you bill on the same day as a lab or x-ray.

Handy tool: If your office deals with several different commercial carriers, you're also probably dealing with several different sets of coding policies. To easily keep track of these policies, develop a chart that links each of the commercial insurance companies to their respective policies on modifiers, Bucknam says.

Note: Even with complete mastery of modifier 25, you'll still encounter denials. And the best way to combat a modifier 25 claim denial is to have a field-tested appeal letter to argue your case.