Primary Care Coding Alert

The next time a patient requires hydration therapy, therapeutic injection, catheterization or a chest x-ray following an E/M service, your procedure pay may depend on modifier 25, thanks to a new batch of edits.

The latest version of the Correct Coding Initiative (CCI), effective April 1, extends the intravenous infusion (90760, 90765) and therapeutic, prophylactic or diagnostic injection (90772-90774) E/M bundles to the facility setting.

CMS bases the injection-inpatient/observation edits on "standards of medical/surgical practice" and allows a modifier breaker. The edit simply codifies a CPT guideline. The "Hydration, Therapeutic, Prophylactic, and Diagnostic Injections and Infusions (Excludes Chemotherapy)" section introductory notes state, "If a significant, separately identifiable Evaluation and Management service is performed, the appropriate E/M service code should be reported using modifier 25 in addition to 90760-90779," says Denae M. Merrill, CPC-E/M, owner of Merrill Medical Management in Saginaw, Mich.

Relief: The new edit doesn't change much, Merrill says. "These services have been bundled together since the creation of 90772 (Therapeutic, prophylactic or diagnostic injection [specify substance or drug]; subcutaneous or intramuscular)."

In fact, the bundles bring CCI in line with CPT. Version 7.3 of CCI said that all codes with "XXX" global periods, such as 90772, include a minor related E/M service, says Barbara J. Cobuzzi, MBA, CPC-OTO, CPC-H, CPC-P, CPC-I, CHCC, president of CRN Healthcare Solutions in Tinton Falls, N.J. Therefore, practices couldn't bill those codes with an E/M service unless they could justify using modifier 25 (Significant, separately identifiable E/M service by the same physician on the same day of the procedure or other service). But each individual carrier was able to decide whether to implement that rule.

"Now that the CCI is bundling some of those codes (such as 90760, Intravenous infusion, hydration; initial, 31 minutes to 1 hour) with E/M services, they-re not leaving it to the carriers anymore," Cobuzzi says.

CCI 14.1 also includes catheterizations (51701-51702, zero global days) and chest x-rays (71010-71020, XXX global days) in many of the pediatric and neonatal critical and intensive care services. Under "CPT manual and CMS coding manual instructions," CCI creates these bundles:

As with the bundles mentioned earlier, these bundles are consistent with CPT guidelines preceding the "Inpatient Neonatal and Pediatric Critical Care and Intensive Services" section. Those guidelines, which were revised for 2008, state that the pediatric and neonatal critical care codes include procedures listed for the hourly critical care codes (99291-99292), among which are 71010-71020.

The CPT guidelines also list 51701 and 51702 as bundled into the pediatric and neonatal critical care codes.

You know you can't just willy-nilly append modifier 25 to the E/M service. The FP must perform and document an E/M service that is significant and separately identifiable from the minor evaluation included in the hydration therapy or therapeutic injection.

Key: To avoid overlooking opportunities to correctly capture a service in addition to the minor procedure, you have to spot E/Ms that qualify as significant and separate.

How it works: An FP evaluates a 2-year-old established patient presenting with vomiting and diarrhea. The child's lips are dry, and his skin is shrunken. The physician performs and documents a level-four office visit during which he diagnoses gastroenteritis with a complication of dehydration. He orders hydration therapy, which lasts 45 minutes.

The scenario meets the significant, separate criteria that modifier 25 requires. Therefore, you may report the office visit (99214, Office or other outpatient visit for the evaluation and management of an established patient -) appended with modifier 25 in addition to the hydration therapy (90760).

Tip: Although CPT does not require separate diagnoses to report a modifier 25 service, linking 99214 and 90760 to the respective ICD-9 codes will help distinguish the E/M from the therapy.