Pulmonology Coding Alert

Do you have the same coding conclusions as our experts?

As you may already know, you have three easy ways to gauge when you're on the right track with reporting modifier 25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service):

The rationale of modifier 25 is that the physician may need 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.

Now take a look at the coding examples we are sharing and check your answers against our experts' advice.

Scenario 1: A Semi-Planned Follow-Up Visit

Your allergist sees Mrs. Jones in the office to evaluate her allergies and plans for a series of allergy injections to improve her respiratory symptoms (wheezing, dyspnea). After the proper testing and identification of the allergens needs for the injections, the allergist's plan includes the preparation of the extract and injections when she returns. Mrs. Jones returns two weeks later. Your physician completes another evaluation prior to administering the first injection.

Code it: Because your physician planned the follow-up visit for the injection service, you should not charge a separate E/M service or include modifier 25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) on your claim unless the patient's situation has changed.

If your physician performs a cursory evaluation on the day of the scheduled procedure in order to rule out any contraindications for carrying out the procedure, and nothing has changed with the patient regarding new diagnoses or problems, you shouldn't code an E/M with modifier 25, or any E/M at all, says Mary Baierl, RHIT, CPC, CCA, CMT, a coder with BayCare Clinic, Pain Management and Rehabilitation Medicine in Green Bay, Wis.

Scenario 2: PFT " a.m.; Office Visit " p.m.

An established patient presents for 6-minute walk test and then sees the physician for evaluation and management of COPD (496, Chronic airway obstruction not elsewhere classified).

Code it: You would report the 6-minute walk test with 94620 (Pulmonary stress testing simple [e.g., 6-minute walk test, prolonged exercise test for bronchospasm with pre- and post-spirometry and oximetry). However, you should also report an E/M service code with the modifier 25 appended to it to indicate that the physician evaluation was provided to evaluate the patient's treatment progress, and not solely for the testing.

Scenario 3: An Unrelated Condition Visit

Your surgeon completes lung biopsy (32095, Thoracotomy, limited, for biopsy of lung or pleura) on Mr. Brown. Six weeks after the surgery, Mr. Brown returns to your office and sees a different physician because of an ankle sprain -- a totally unrelated procedure.

Code it: Although Mr. Brown returned to your office within the 90-day global period of the surgical service, he came for a problem unrelated to the lung surgery and saw a different physician. Although coders see the second visit as "separately identifiable," Baierl warns that appending modifier 25 not an option. If you refer to the basic rules of using modifier 25, you'll see that the separate and identifiable E/M service must be provided on the same day as a minor procedure (i.e., 0 or 10-day global period).

"Since you don't have a 'minor' procedure preceding the visit for the ankle sprain, modifier 25 is inappropriate," Baierl adds. The lung biopsy is a major procedure and has a 90-day global period which includes all related postoperative care by the surgeon/group for 90-days after the procedure. Although the patient saw another surgeon in the same group, the visit for the ankle sprain was unrelated to the lung surgery and can be reported with the appropriate E/M code and modifier 24 (Unrelated evaluation and management service by the same physician during a postoperative period.)