Pulmonology Coding Alert

Question: Insurers often deny our practice's claims when we attach modifier -25 to a code. Do you have any tips on how to avoid denials with this modifier?
New York Subscriber

Answer: Pulmonology coders can avoid denials and lost reimbursement if they know how to appropriately report modifier -25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service). Review the following quick tips to help avoid denials, and check with your carrier for its specific guidelines for modifier -25.
 
1. Append modifier -25 only to E/M services. Do not use the modifier on any procedure codes. You should use modifier -25 with an E/M service (for example, 99211, Office or other outpatient visit ... established patient ...) that the pulmonologist performs on the same day as another procedure, such as thoracostomy (32020, Tube thoracostomy with or without water seal [e.g., for abscess, hemothorax, empyema] [separate procedure]).  
 
2. Do not append modifier -25 to E/M codes when the only other codes you use for that claim represent ancillary services, such as x-rays (71010, Radiologic examination, chest; single view, frontal). Also, most insurers prohibit practices from using modifier -25 with an E/M service that leads to a major surgical procedure, which carries a 90-day global period. Often you should attach modifier -57 (Decision for surgery) when an office visit leads to surgery and the visit occurs the day before or the day of surgery. Make sure to check with your insurer for additional restrictions and guidelines. 
 
3. Include separate documentation for both your E/M and procedure codes. To medically justify reporting both an E/M code and a procedure code, you should supply separate documentation for each service, coding experts say. 
 
For instance, a patient's primary-care physician requests a consultation from your physician to evaluate the patient for painful respiration (786.52) and wheezing (786.07). Following an exam and x-rays, which reveal pleural effusion (511.9), your physician decides to perform diagnostic thoracentesis (32000, Thoracentesis, puncture of pleural cavity for aspiration, initial or subsequent) to remove fluid.
 
In that case, you could report 32000 and an office consult code, such as 99244, for the evaluation. By appending modifier -25 to 99244, you let Medicare know that the pulmonologist performed the E/M service separately from the thoracentesis. You would also link 786.52 and 786.07 to 99244, and assign 511.9 (Unspecified pleural effusion) to 32000. You should use 511.9 as the diagnosis code unless the physician provides a more specific diagnosis, such as 511.1 (Pleurisy; with effusion, with mention of a bacterial cause other than tuberculosis).