Pulmonology Coding Alert

Separate, significant, and same day spell successful application.

When you attach 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) to a code, you’ll always face scrutiny by watchdogs in the healthcare industry.

“Appropriate use of modifier 25 has often been on the Office of the Inspector General’s [OIG’s] Annual Work Plan,” cautions Marcella Bucknam, CPC, CCS-P, COC, CCS, CPC-P, CPC-I, CCC, COBGC, compliance office with University of Washington Physicians in Seattle, Washington. “The OIG reviews use of modifier 25 and may audit organizations that overuse the modifier. This is also true of Medicare Administrative Contractor [MAC] and Recovery Audit Contractor [RAC] audits.”

So, to help you avoid intrusive and painful reviews, here are three rules to remember before employing one of the most used — and misused — modifiers in coding.

Rule 1: 25 Means Separate and Same Day

The key to using modifier 25 correctly is to read the modifier’s descriptor closely and carefully. Simply put, you have incorrectly applied the modifier:

• If an evaluation and management (E/M) service is not performed on the same day as another procedure or service
• If the E/M service is not significant or separate from the other procedure or service
• If the same physician or qualified healthcare professional (QHP) did not perform both the E/M service and the procedure (or if either service was performed by someone other than a physician or QHP)

Example: An established patient presents for a routine follow-up to review their chronic obstructive pulmonary disease (COPD) and medication. Your provider reviews the history of the patient’s current illness, examines the patient, and orders lab work to evaluate the effect of the prescription. While the provider is examining the patient, the patient complains of trouble taking a deep breath and is audibly wheezing. The physician decides to give the patient a breathing treatment to see if the symptoms improve. The provider administers 2.5 mg of albuterol and 0.5 mg of ipratropium bromide via a nebulizer. After the procedure, the patient’s symptoms subside, and the physician prescribes a few weeks of home nebulizer therapy as needed.

You will code 94640 (Pressurized or nonpressurized inhalation treatment for acute airway obstruction for therapeutic purposes and/or for diagnostic purposes such as sputum induction with an aerosol generator, nebulizer, metered dose inhaler or intermittent positive pressure breathing (IPPB) device) for the procedure, J7620 (Albuterol, up to 2.5 mg and ipratropium bromide, up to 0.5 mg, FDA-approved final product, non-compounded, administered through DME) for the inhalation solution, and 99214 (Office or other outpatient visit for the evaluation and management of an established patient, which requires a medically appropriate history and/ or examination and moderate level of medical decision making. When using total time on the date of the encounter for code selection, 30 minutes must be met or exceeded.) for the follow-up E/M, appending modifier 25 to 99214.

In this situation, the provider performed significant, extra, and separate work in the assessment and plan to treat the patient’s exacerbation. This means you can bill an E/M service separately using modifier 25.

Coding caution: In general, you would use modifier 25 on E/M services performed in conjunction with minor procedures that have a 0- or 10-day global period. Procedures with a 90-day global period will typically take modifier 57 (Decision for surgery). It is imperative that you consider National Correct Coding Initiative (NCCI) edits. The global period for 94640 is XXX (global period does not apply). However, NCCI bundles 99214 into 94640 unless documentation supports adding a NCCI-appropriate modifier, so 25 would be the correct modifier to append to the E/M in this case.

And, as modifier 25 is for a separate and significant E/M, you should only append it to the E/M code and never to the additional same-day procedure code.

Rule 2: Look for Significant Additional Services and Dx

If your provider’s visit documentation describes more than the pre- and post-work for the procedure, there is a potential for reporting a significant and separate E/M.

For example, additional work ups such as labs or diagnostic tests, X-rays, or studies, providing they are unrelated to the procedure, or even making medication changes will build a strong case for an E/M code plus modifier 25.