Pulmonology Coding Alert

Question: When should I use modifier -25 instead of modifier -57?

Hawaii Subscriber

Answer: You should attach modifier -25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) to an E/M code to show that the pulmonologist performed the E/M service separately from another office visit or procedure.
 
For example, after a physician provides critical care services (99291) to a patient with acute respiratory failure (518.81), the physician subsequently discovers that the patient has atelectasis (518.0, Pulmonary collapse). The pulmonologist then performs a diagnostic bronchoscopy (31622, Bronchoscopy, rigid or flexible, with or without fluoroscopic guidance; diagnostic, with or without cell washing [separate procedure]).
 
To report these services, you use codes 99291-25 (Critical care, evaluation and management of the critically ill or critically injured patient; first 30-74 minutes) and 31622 (diagnostic bronchoscopy).
 
When an E/M service leads your physician to perform surgery, you should append modifier -57 (Decision for surgery) to the E/M code.
 
For instance, the physician provides an inpatient consultation (99251-99255) on a patient with a hemothorax (511.8, Other specified forms of effusion, except tuberculous), and decides to perform a tube thoracostomy (32020, Tube thoracostomy with or without water seal [e.g., for abscess, hemothorax, empyema] [separate procedure]) to drain the fluid.
 
In that case, you would attach modifier -57 to one of the consultation codes (99251-99255) to indicate that an E/M service resulted in the initial decision to perform surgery. The coding sequence would be 9925x-57, 32020.