Primary Care Coding Alert

Family practitioners commonly see their patients for preventive-care visits, but how should they code when the patient also mentions a specific problem during the appointment? Consider a 30-year-old established male patient who comes in for his annual physical exam (periodic preventive medicine, 99395) but while he is in the family doctors office complains of a sore knee. The physician takes the time to examine the joint, questioning how long it has hurt, how severe the pain is and what may have caused it. The family doctor prescribes medication for tendonitis and tells the patient to return in a week for a follow-up. In addition to the preventive-care office visit, the family physician dealt with a specific problemthe sore knee. Accordingly, you also could code 99213 (office or other outpatient visit of low complexity) appended with modifier -25.

Kent Moore, manager of reimbursement issues for the American Academy of Family Physicians (AAFP), says that some family doctors tend to undercode by lumping both services together, while others bill the problem-oriented examination at a higher level than appropriate. To add one more bit of confusion, he says, not all carriers are set up to recognize modifiers. The CPT guidelines clearly state that modifier -25 is a significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service. In short, the modifier is used to indicate services undertaken in addition to an office visit.

Although many carriers interpret separately identifiable service to mean unrelated to the service performed, the Health Care Financing Administration (HCFA) says: A documented, separately identifiable related service is to be paid. We would define related as being caused or prompted by the same symptoms or conditions.

Thomas Kent, CMM, principal of Kent Medical Management, a medical office management and coding consulting firm in Dunkirk, MD, has three rules of thumb for using modifier -25:

1. Attach modifier -25 to the office visit, not a procedure or other service performed.

2. Document the office visit separately from the procedure or other service on the claim form.

3. Dont discount your services. Charge 100 percent for both the office visit and the procedure or other service provided for the problem.

Kent points to several examples that help explain the use of modifier -25. He recalls an incident in which a mother brought her child in for halitosis. Although the cause was a piece of gauze the child had stuck up his nose, the physician didnt know this when she began her exam.

Accordingly, she could bill 99213 (office or other outpatient visit with low-complexity medical decision-making) with modifier -25 attached because she had to take a patient history, perform an examination, and make a medical decision of low complexity to determine the cause of the bad breath, and also remove the foreign body (30300*, removal foreign body, intranasal; office type procedure). On the other hand, had the mother brought the child in because she knew he had gauze up his nose, the family physician could bill only for the procedure and not for an office visit since a detailed examination was not necessary. The removal of the gauze is all the physician would need to perform.

In another example, an established patient visits the family doctor with both strep throat and a corn on his toe, which is continually irritated and sometimes bleeds. Kent says the family physician can bill for the strep problem first with 99213 (office visit) with modifier -25 attached, plus a 11055 (paring or cutting of a benign hyperkeratotic lesion) for the corn. If there is an examination, medical history and decision-making with a procedure, use modifier -25, Kent emphasizes. Most visits for a new patient will have a procedure and a need for an evaluation first so you need to use modifier -25.

Susan Callaway-Stradley, CPC, CCS-P, an independent coding consultant in Augusta, GA, and the American Academy of Professional Coders 1998 Coder of the Year, compares two office visits and why one merits modifier -25 and the other doesnt:

1. A patient comes in with a cut hand and the family doctor cleans it, applies sutures, and questions when the patient last had a tetanus shot. The physician may bill the appropriate laceration repair code.

2. On the other hand, a patient comes in with a gash in the head, so the family doctor cleans it, applies sutures, inquires about the tetanus, but also performs a neurological exam because the patient is experiencing dizziness. That exam constitutes a significant level of service, so the modifier -25 should be attached to the office visit code (99201-99215), she explains.

One or Two Diagnoses?

Greg Schnitzer, RN, CPC, CPC-H, CCS-P, audit specialist with the Office of Audit and Compliance, University of Pennsylvania in Philadelphia, points out another area of controversy regarding the definition of modifier -25. Some payers say they will only reimburse for an office visit and procedure on the same day if the diagnostic codes for both are different. The American Medical Association (AMA) recently said that diagnoses no longer have to be different because the E/M service may be prompted by the symptom or condition for which the procedure and/or service was provided. This may be reported by using modifier -25 or the separate five-digit modifier 09925 (substitute for -25), which is not as common.

Although some carriers say you have to have two different diagnoses, its not necessary. But the chances of reimbursement are greater with different ones, Kent says. You can often use the sign or symptom as the second diagnostic code (as indicated in the above case of the little boy with bad breath).

Note: Modifier -25 should not be confused with modifier -59, a distinct procedural service. According to CPT, -59 is used to identify procedures/services that are not normally reported together but are appropriate under the circumstances. The AMA, however, says that modifier -59 should not be used if a more descriptive modifier is available.