Pulmonology Coding Alert

Remember: Only append this modifier to E/M codes - never to procedure codes.

Most coders are essentially experts at appending modifier 25, and you'd think that would be a good thing - but it isn't always. Some practices have become so complacent with modifier 25 that they've forgotten to stick to the rules required for using it.

Here's why: "Proper application of evaluation and management codes [E/M] codes and modifier 25 has been a longtime challenge for physician coders," says Mary I. Falbo, MBA, CPC, CEO of Millennium Healthcare Consulting, Inc. in Lansdale, Pennsylvania.

Fortunately, hope is not lost. You can make your modifier 25 (Significant, separately identifiable evaluation and management service by the same physician or other qualified health care professional on the same day of the procedure or other service) coding foolproof, whether it's your first or 101st claim with the modifier. Check out the following myths about the modifier, along with expert tips on the realities of using it.

Myth 1: You Should Append Modifier 25 to Your Procedure Codes When Billed With An E/M

Reality: You can apply modifier 25 to an E/M service that is separate and significant from another procedure or service at the same encounter, said Melanie Witt, RN, CPC, MA, an independent coding expert based in Guadalupita, New Mexico. "The note must clearly indicate that the E/M dealt with issues that were not part of the other services," she continues. However, you can never use modifier 25 on a procedure code; the modifier is for use on E/M codes only.

When you use modifier 25, it indicates that "on the day of a procedure, the patient's condition required a significant, separately identifiable E/M service, above and beyond the usual pre- and postoperative care associated with the [other] procedure or service," explains Falbo.

The procedure that accompanies the E/M must be minor in order to report an E/M-25 along with a CPT^® code, reminds Catherine Brink, BS, CMM, CPC, president of Healthcare Resource Management in Spring Lake, New Jersey. For coding purposes, a minor procedure is one that has a global surgical period of zero to 10 days. If the global period for the procedure exceeds 10 days, you shouldn't use modifier 25 for a separate E/M.

Myth 2: You Need Multiple Diagnosis Codes to Bill E/M, Procedure Code

Reality: This is not necessarily true. Sometimes, a patient will report for a procedure and then require a separate E/M for some other condition. In pulmonology practices, however, you'll also see modifier 25 claims with the same diagnosis for the E/M and the procedure. This is perfectly allowable - provided you apply the modifier rules properly.

"Different diagnoses are not required for reporting of the E/M services on the same date, but it is necessary that there be medical necessity to perform the separate service and that the E/M service provided goes beyond the normal preoperative work that is part of every procedure," explains Falbo.

"Additionally, Medicare specifies that the decision to perform a minor procedure in itself is not sufficient justification for [an E/M with] modifier 25. There must be documentation that the service went beyond the evaluation needed to determine the need for the procedure," Falbo continues. In other words, did the evaluation result in the initial decision for a procedural service, or was the decision made at the previous visit in which case the physician has to perform a preprocedural examination to ensure the patient can still undergo the planned procedure? The latter is not separately billable.

The key to successful modifier 25 claims "is recognizing when your extra work is 'significant' and, therefore, additionally billable," says Falbo. While CPT^® does not define "significant," Falbo recommends asking yourself these questions to see if the extra work qualifies for an E/M-25:

• Did you perform and document the key components of a problem-oriented E/M service for the complaint or problem?
• Could the complaint or problem stand alone as a billable service?
• Is there a different diagnosis for this portion of the visit?
• If the diagnosis will be the same, did you perform extra physician work that went above and beyond the typical pre- or postoperative work associated with the procedure code?

Myth 3: Modifier 25 Is All You Need to Prove Medical Necessity for Separate E/M, Procedure

Reality: There is only one way to prove medical necessity for the separate E/M and procedure, and that is to have clear documentation. Typically, you won't submit documentation on your modifier 25 claims, but if the payer denies the claim you'll have to provide documentation on appeal.

A separate diagnosis is always a good method to prove significantly separate services, but you won't always have different ICD-10 codes for the procedure and the E/M-25. Proper documentation for some E/M-25 encounters might include "a separate plan of care for the problem - for example, prescription drug management or ordering studies," Falbo says. Also, if you make it clear in the documentation that the provider reached the decision to perform the procedure after performing the history and exam, and the physician notes it in his plan of care, it could go a long way toward solidifying your E/M-25 claims.

Bottom line: No matter how you do it, medical record documentation is key to substantiating that an E/M was medically necessary in addition to the work involved in a procedure for the same patient during the same visit. Make sure to get your notes right before submitting an E/M-25, so you'll be ready if the payer requires you to appeal the claim.