Primary Care Coding Alert

Improve your procedure-related coding with solid understanding of modifier 25

Two astute Family Practice Coding Alert readers noticed possible inconsistencies in the publication's advice on billing an E/M service with a minor procedure. The June 2006 Family Practice Coding Alert -Reader Questions: Check Diagnosis for I&D for Testicular Pain- suggests -that a physician cannot bill for an E/M when a procedure is done at the same visit,- says Kris Cuddy, CPC, with Mid-Michigan Physicians. -This same issue offers an article describing how the physician may bill for cerumen impaction removal and an E/M on the same day.-

To make matters more confusing, the March 2006 Family Practice Coding Alert reader question -Review Insurer's Modifier Policies- describes a patient who comes in for a non-healing spot on his hand. The FP diagnoses the spot as a common wart and uses cryosurgery to destroy it. 

-The answer indicates billing E/M 99212-25 and 17000 (Destruction [e.g., laser surgery, electrosurgery, cryosurgery, chemosurgery, surgical curettement], all benign or premalignant lesions other than skin tags or cutaneous vascular proliferative lesions; first lesion) for destruction of the wart,- says Sharon Carson, outpatient coder at Spooner Clinic, part of the St. Mary-s/Duluth Clinic Health System in Minnesota.

Before you get the lowdown on what makes these scenarios different and the factors that led to the recommendations, make sure you have a solid grasp of these modifier 25 principles. 

Review CPT's Procedure Inclusion Statement

You probably know that modifier 25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) refers to a -significant, separately identifiable evaluation and management service- but you may overlook its extended definition.  -For you to bill a modifier 25-appended service, the E/M service must be over and above the procedure's pre- and post-op work,- says Vicky V. O-Neil, CPC, CCS-P, coding and compliance educator in St. Louis, Mo.
 
This principle stems from CPT's modifier 25 language. In Appendix A of the CPT 2006 manual, the AMA explains that you may need to use modifier 25 -to indicate that on the day a procedure or service identified by a CPT code was performed, the patient's condition required a significant, separately identifiable E/M service above and beyond the other service provided or beyond the usual preoperative and postoperative care associated with the procedure that was performed.-

Tip: Documentation will probably meet modifier 25's criteria if you can draw a line between the E/M service and the procedure to show the separate nature of the two charges. In the first paragraph, the physician should document a history, an exam and the medical decision-making that led to the decision to perform the procedure, says Barbara J. Cobuzzi, MBA, CPC, CPC-H, CPC-P, CHCC, president of CRN Healthcare Solutions, a coding and reimbursement consulting firm in Tinton Falls, N.J.
 
He should write the procedure note in a separate paragraph. If the E/M service history, exam, and medical decision making can stand alone, report the modifier 25-appended appropriate code.

Look for More Than a Pre-Op's -No or Go- E/M

Auditors may maintain that the above history, exam and medical decision-making are part of the procedure's preoperative service. -No specific documentation exists as to what the preoperative E/M entails,- Cobuzzi says.

So, how can you determine if your FP's documentation supports a separately identifiable E/M service?

Solution: See if the documented E/M is more than the services that a scheduled minor procedure includes. Think of what your FP would do preoperatively for a scheduled wart or cerumen removal, Cobuzzi says. -That is the pre-op E/M.-

To bill a 99212-99215-25, make sure documentation shows that the physician performed much more than a scheduled 17000's or 69210's (Removal impacted cerumen [separate procedure], one or both ears) preoperative service, in which the FP makes sure the procedure is a -no- or a -go.-

Realize Same Dx Is OK

Don't assume that the E/M service has to be unrelated to the procedure. -Different diagnoses are not required for reporting the E/M service on the same date as the procedure or other service,- according to The CMC Group, headed by Sean Weiss, CPC, CMPE, RMM.

CPT's modifier 25 explanation confirms the same- diagnosis-is-OK rule. -The E/M service may be prompted by the symptom or condition for which the procedure and/or service was provided,- states the AMA in Appendix A: Modifiers of the CPT manual.