Pulmonology Coding Alert

Many common pulmonology procedures are considered to have evaluation and management (E/M) services bundled into them as an inherent part of the procedure. For these procedures, coders cant report E/M in addition to the procedure code. In some cases, a physician has performed an extra E/M service that he or she considers separate from the procedure. To get reimbursed for the extra service, coders should add the E/M code to the claim with modifier -25 (significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service).

Since Oct. 30, 2000, the HCFA has required the use of modifier -25 for these separate E/M services. Coders can bill for these services separately only if they use modifier -25.

Now physicians must verify by the use of modifier -25 that a significant, separately identifiable E/M was performed, rather than just the basic information-gathering and delivery of results performed as a standard part of all procedures, according to Susan Callaway, CPC, CCS-P, an independent coding consultant and educator in North Augusta, S.C.

This new policy, proposed by HCFA in Section H of the Nov. 2, 1999, Federal Register, was implemented in the national Correct Coding Initiative (CCI) edits with version 6.3. More than 50,000 codes were affected by the policy shift, including those commonly used by pulmonary physicians.

Because every procedure has an inherent E/M component, for an E/M service to be paid separately, a significant, separately identifiable service would need to be documented in the medical record, HCFA stated.

Modifier -25 Is Critical to Pulmonary Coding

Some coders who have reported separate E/M procedures performed on the same day as pulmonary procedures have not received payment since the ruling went into effect. If they had used modifier -25, their claims might not have been denied.

The news about modifier -25 is extremely important to pulmonary billing for critical care, says Walter J. ODonohue Jr., MD, FCCP, representative to the AMA CPT advisory committee for the American College of Chest Physicians and chief of pulmonary/critical care at the University Medical Center in Omaha, Neb. In some cases, the E/M service is the whole treatment, and a physician would bill only for that service.

ODonohue suggests the example of another physician sending a patient to the pulmonologist just to have a bronchoscopy (31622, bronchoscopy [rigid or flexible]; diagnostic, with or without cell washing [separate procedure]). Then the pulmonologist would take the patients history and perform the bronchoscopy, sending the results back to the referring physician. The pulmonologist couldnt also bill for separate E/M services.

But if a doctor sends a patient to be evaluated for a cough, and the pulmonologist does an examination and, [...]