Pulmonology Coding Alert

Carriers may soon crack down -- are you prepared?

Knowing when you should append modifier 25 can be hard enough -- and thanks to a new transmittal from the Centers for Medicare & Medicaid Services, your modifier 25 claims may be even more of a hassle. Now is the time to sit up and pay attention, making sure your physician's documentation supports modifier 25.

Take Note of 3 Key Points

Your documentation supporting the use of modifier 25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) will be under heavy scrutiny soon, judging from Transmittal 954, issued May 19 by CMS.
 
Clarification #1: CMS has added the word "usual," so the guidelines for modifier 25 now read: "a significant, separately identifiable E/M service that is above and beyond the usual pre- and postoperative work for the service." The addition is just meant to emphasize that any extra E/M service must be "above and beyond" the typical pre-op or post-op work, says Quinten Buechner with ProActive Consultants in Cumberland, Wis.
 
Clarification #2: Transmittal 954 clarifies that you don't need a different diagnosis for the E/M service and procedure or surgery to be able to use modifier 25.
 
Clarification #3: You'll now also need to make sure that you have appropriate documentation that proves the medical necessity of the separate same-day E/M service your pulmonologist provided. You don't need to submit this documentation with the claim, but it must be available upon request.

Stress 'Significance' in Documentation

The guidelines for using modifier 25 haven't actually changed, says Stacie L. Buck, RHIA, CCS-P, LHRM, vice president of Southeast Radiology Management in Stuart, Fla. "CMS is issuing clarification in light of the findings in the OIG's report on modifier 25." The Office of Inspector General found a 35 percent error rate for modifier 25 -- and $538 million in improper payments -- in its sample of claims from 2003.
 
But it's safe to say your modifier claims will be under more scrutiny. "I strongly believe providers will see more and more claims with 25 subjected to pre-   and postpayment review because of the OIG findings," Buck says.
 
Be proactive: All procedures, from simple injections to common diagnostic tests, include an "inherent" E/M component, according to CMS guidelines. Therefore, any E/M service you report separately must go "above and beyond" the minimal E/M that normally accompanies such a procedure.
 
When you're considering whether you should append modifier 25 to an E/M service code when your pulmonologist performs an E/M service and another procedure or service, follow these three tips:
 
• Make sure your claim includes E/M services that are significant and separately identifiable. The E/M should be above and beyond the usual preoperative and postoperative care associated with the procedure.
 
• Focus on compiling complete documentation of both the procedure and the separate E/M.
 
• Don't append modifier 25 if an E/M is the only service your physician provides the patient that day.

Best practice: Ask your pulmonologist to document the E/M and the procedure in separate paragraphs so you can easily identify their separate nature. "Physicians and coders need to make sure that the documentation clearly supports both services and that all guidelines are followed," Buck says.
 
Bottom line: If your pulmonologist performs a separate, identifiable service or procedure along with an E/M service, report both services and append modifier 25 to the E/M code. If the physician schedules a procedure and merely performs the necessary pre-op H&P, don't bill for a separate E/M.
 
But if your pulmonologist doesn't know if an operation will be necessary and must rule out other options, you can bill for the E/M in which the doctor reaches the decision for surgery. In other words, if the physician develops a new care plan or revises an existing care plan, he most likely provided a separate E/M.
 
Example: A patient comes into your office for a scheduled flu vaccination and then also sees your pulmonologist for new symptoms such as coughing and shortness of breath. You can report the separately identifiable E/M service with the injection code using modifier 25.
 
Report the flu shot injection using the appropriate administration and vaccine codes, such as 90656 (Influenza virus vaccine, split virus, preservative-free, for use in individuals 3 years and above, for intramuscular use) and 90471 (Immunization administration [includes percutaneous, intradermal, subcutaneous, or intramuscular injections]; one vaccine [single or combination vaccine/toxoid]).
 
Then report the appropriate established patient visit code based on the level of service (99212-99215, Office or other outpatient visit for the evaluation and management of an established patient).
 
Pitfall: Do not arbitrarily assign 99211 (Office or other outpatient visit for the evaluation and management of an established patient, that may not require the presence of a physician) with previously scheduled injections provided by a nurse. The nurse must also provide a separate service in order to report 99211, such as medication teaching for the non-compliant patient.