Pulmonology Coding Alert

Hint: Clear documentation will back up your modifier 25 claims.

How do you correctly bill for procedures, equipment, and services if the codes available don’t accurately sum up what happened with the patient? You append the applicable code with an appropriate modifier to ensure you precisely convey what took place during an office visit, a surgical procedure, or in a testing facility.

“Modifiers are appended to CPT^® and HCPCS Level II codes to report specific circumstances or alterations to a procedure, service, or medical equipment without actually changing the definition of the CPT^® code. Modifiers help to tell an additional piece of the story to that procedure,” says Sherrie Lynne Anderson, MS, CPC, CPC-I, CPPM, CRC of the Revenue Cycle at the Washington University Department of Neurology, School of Medicine in a webinar on modifiers.

To improve your coding precision, see if you can bust these two modifier myths.

Myth 1: You Only Need Modifier 25 to Show Medical Necessity for a Separate E/M Visit and Procedure

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) is one of the most used modifiers in the CPT^® manual, and it is also applied incorrectly too often. When you carefully read the descriptor, you’ll notice three components that are necessary for its use — the E/M visit and procedure must occur on the same day; the same physician or qualified healthcare provider (QHP) must perform these services; and you need to identify the significantly separate services. While your report may show that an E/M visit and a procedure occurred on the same day, you’ll need more information to back up why the procedure was necessary at the time of the visit.

Scenario: A patient comes in for an annual follow-up evaluation and management (E/M) visit to renew their asthma medication prescription. During the E/M visit, they mention to the pulmonologist that they have been experiencing a lingering cough for a couple of weeks. The pulmonologist listens to the patient’s lungs and orders chest X-rays and spirometry. The physician then diagnoses the patient with acute bronchitis (J20.9 Acute bronchitis, unspecified).

Reporting tip: If you append your E/M code with modifier 25, the easiest way to prove the medical necessity for an E/M visit and procedure is to have clear documentation. A foolproof method to prove the services are significantly separate is to have a separate diagnosis, but you may not have different ICD-10-CM codes for the procedure and the E/M visit.

“As we are aware, modifier 25 is extremely scrutinized by payers. The service must be supported and proven to be a separately identifiable evaluation and management to help prevent or reduce denials of payment,” Anderson adds. If it’s clear in the documentation that the provider decided to perform a procedure after assessing the patient’s complaints, it could be beneficial to solidify your E/M claim with modifier 25. With this scenario, the evaluation of the patient’s cough led to the decision for diagnostic testing, which resulted in the bronchitis diagnosis.

You should check individual payer guidelines for the correct way to bill in your situation. Depending on the payer, you may not need modifier 25 on the claim, but if your claim is denied, you’ll be able to provide precise documentation for the appeal.

Myth 2: Modifier 59 Can Be Applied to Any CPT^® Code for Reimbursement

You cannot apply modifier 59 (Distinct procedural service) to any CPT^® code, and it’s often misused in a variety of different ways. This modifier is known as the “unbundling modifier” because it’s often used to code separate procedures and services that aren’t usually reported together and override National Correct Coding Institute (NCCI) edit pairs. Using NCCI, CMS has determined that you should not report a certain pair of CPT^® or HCPCS codes together because the service described in the column two code is considered to be overlapping with, or part of, the service described by the column one code. However, while certain code pairs shouldn’t be reported together, you can often use modifier 59 to unbundle the codes.

Scenario: A 24-year-old patient comes into your pulmonology practice presenting symptoms of an exacerbation of asthma, and the physician administers an inhalation treatment. Following the treatment, the pulmonologist prescribes a new metered dose inhaler (MDI) with the addition of an aerochamber on the same date of service. The physician also instructs the patient on the proper use of the MDI.

In this scenario, you would code the treatment with 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) and the instruction on how to use the inhaler with 94664 (Demonstration and/ or evaluation of patient utilization of an aerosol generator, nebulizer, metered dose inhaler or IPPB device). CPT^® code 94664 is a different service from the initial treatment, and NCCI lists it as a column two code in this code pairing. However, the edit has a modifier indicator of “1,” meaning that the pair can be unbundled. So you can append modifier 59 to 94664 to unbundle the pair.

Reporting tip: Some private insurers and Medicare or Medicaid carriers could deny the claim — but you should check individual payer guidelines for the correct way to bill in this situation. If you do notice that you put modifier 59 on the wrong code, you will need to correct the claim and resubmit. In this situation, you may need to append one of Medicare’s X{EPSU} modifiers, such as XU (Unusual non-overlapping service) on the 94664.

Note: You should not append modifier 59 to E/M services. If you need to report an E/M code with a separate, distinct non-E/M code service performed on the same day, you’ll use modifier 25.