Pulmonology Coding Alert

When -25 doesn't cure your E/M pay problems, modifier -57 may do the trick If you want to recoup reimbursement for your modifier -25 claims, make sure you can identify your physician's E/M services separately from his other procedures, such as a bronchoscopy performed on the same patient on the same day as another E/M procedure. And if the physician makes the decision for surgery during the E/M visit, choose modifier -57 instead of -25. Bronchoscopy is a procedure that allows the physician to use a bronchoscope (fiberoptic or rigid) to enter the larynx, trachea and bronchi, says Alan L. Plummer, MD, professor of medicine in the division of pulmonary, allergy and critical care at the Emory University School of Medicine in Atlanta. Once the physician establishes entrance, he says, the physician looks for abnormalities, and he biopsies any suspicious lesions and obtains washings or lavages specimens for diagnostic purposes.

Example: A patient comes to your practice for a follow-up visit. He has chronic obstructive pulmonary disease (COPD) and he's an ex-smoker. He informs your physician that he has a new complaint of hemoptysis, and the physician takes a chest x-ray. The x-ray indicates a suspicious shadow in the right hilar area. The physician decides to perform a bronchoscope on the patient the same day, Plummer says.

Coding options: You could code the office visit with the E/M code for a low to moderate problem (99214, Office or other outpatient visit ...) since the physician identified a new problem at a routine follow-up visit. You should add modifier -25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) to indicate that the physician performed a separate procedure from the E/M visit on the same day of the examination. You should code the bronchial biopsy with 31625 (Bronchoscopy, rigid or flexible, with or without fluoroscopic guidance; with bronchial or endobronchial biopsy[s], single or multiple sites).

Here are three easy questions to ask yourself -- with answers from the experts -- to help guide you on the road to hassle-free use of modifier -25. 1. Does your E/M service stand alone? CMS specifies that all procedures have an inherent evaluation and management component. Private payers also assume there's some inherent E/M visit built into the reimbursement for procedure codes, because most procedures require the physician to perform a "preoperative" history and physical.

This is why you need to be careful not to overuse modifier -25. Don't append modifier -25 just because your pulmonologist spoke with the patient before doing the procedure, says Brenda W. Messick, CPC, a coding specialist in Atlanta. For Medicare, to properly code using modifier -25, the [...]