Pulmonology Coding Alert

Learn why 24 and 57 are most likely not appropriate modifiers

When you need to report an E/M service with a pulmonology procedure, you'll most likely consider three modifiers: 24, 25 and 57. To make that job easier, you should follow these expert tips to learn how global periods affect your modifier use.

Pay Attention to Each Modifier's Rule of Use

You may find that deciding among modifiers 25, (Significant, separately identifiable E/M service by the same physician on the same day of the procedure or other service), 24 (Unrelated E/M service by the same physician during a postoperative period) and 57 (Decision for surgery) is confusing because you can append all three to E/M codes. Yet, remember that 25 is almost always the correct modifier for pulmonology coders to use, says Carol Pohlig, BSN, RN, CPC, senior coding and education specialist at the University of Pennsylvania department of medicine in Philadelphia.

You should not append modifiers 24 and 57 to E/M services that pulmonologists perform because of the global-period restrictions on the modifiers, Pohlig says. The global-surgical-package rules bundle services (including E/M services) typically associated with the surgical procedure into the surgical procedure. You can use modifiers 24, 25 and 57 to appropriately overcome bundles, but each of these modifiers has different rules of use.

Use Modifier 25 in Most Cases

When your physician performs an E/M service and then a pulmonology procedure, your challenge is to figure out if carriers permit you to report both services. Most common pulmonology procedures, such as bronchoscopies and thoracentesis, carry a zero-day global period, Pohlig says.

All E/M services provided pre- or postoperatively that are related to these procedures and that your physician performs on the same day are bundled into the procedure. This means that, when applicable, you need to use modifier 25 to report a separate E/M service. Modifier 25 is the only modifier you can use to report a significant, separately identifiable E/M service your physician performs on the same day as a bronchoscopy or a thoracentesis.

Example: An established patient presents to your practice with severe coughing and chest pain. Your pulmonologist performs an evaluation and orders a chest x-ray, which reveals a pleural effusion. He then decides to perform a thoracentesis procedure on the same day.
 
To capture payment for both the office visit and the procedure, report 99213 (Office or other outpatient visit for the evaluation and management of an established patient ...) for the E/M service and 32000 (Thoracentesis, puncture of pleural cavity for aspiration, initial or subsequent) for the procedure. Attach modifier 25 to 99213 to indicate that the visit was a separately identifiable service during which the physician decided to perform the procedure.

Assign chest pain (786.50) and cough (786.2) to the E/M visit, and report the thoracentesis with pleural effusion (511.9).

Save Modifier 57 for Major Surgery

You may think that you should append modifier 57 to an E/M service that your pulmonologist performs prior to a surgery later the same day. When your physician performs an E/M service on the day before or day of a procedure, it might look like a pre-op visit. Modifier 57 shows carriers that an E/M service really is separately payable because that is when the physician decided to perform surgery, says Laureen Jandroep, OTR, CPC, CCS-P, CPC-H, CCS, a leading national authority on medical coding and reimbursement.
 
"The 57 modifier indicates the decision for surgery, so a lot of physicians tend to think that if they provide a consultation resulting in the decision to perform a bronchoscopy procedure, they made the decision for surgery," Pohlig says. You can only use modifier 57 with major surgical procedures that carry a 10- or 90-day global period. No standard pulmonology procedures carry a 10- or 90-day global period. Therefore, modifier 57 is not the correct modifier for you to attach to the E/M service code.

Note: If your pulmonology practice includes thoracic surgeons or if your pulmonologist is expanding her practice to provide more extensive surgical procedures, modifier 57 may be appropriate in some cases. Many thoracic surgery procedures, such as thoracoscopy with pleurodesis (32650, Thoracoscopy, surgical; with pleurodesis [e.g., mechanical or chemical]), carry a 90-day global period. With this type of surgery, you can append modifier 57 to the separate E/M code when the physician makes the decision for surgery the day before or the day of surgery, Pohlig says. You don't have to attach a modifier to report a visit that occurs more than the day before the surgical procedure.

Modifier 24 Depends on Post-Op Guidelines

The other E/M-only modifier that you might look at when you're reporting a separate E/M is modifier 24. This modifier applies to a separate E/M service the physician performs during a postoperative procedure. "If you are not in the global period, it does not apply," Jandroep says.

Because most pulmonology procedures have a zero-day global period, there really is no postoperative period. So modifier 24, which is meant for E/M services that occur after procedures that have 10- or 90-day postoperative periods, isn't appropriate, Pohlig says.

Example: A patient with a recurring, persistent pleural effusion (511.9) undergoes a thoracoscopy with pleurodesis from a thoracic surgeon. The patient calls the thoracic surgeon at six weeks because of rhinorrhea, cough and fever. The physician calls the patient into the office and examines her, then he prescribes an antihistamine and antibiotic for an acute sinusitis.

You should code an office visit (99211-99215) for this encounter and append modifier 24 to indicate that the visit was totally unrelated to the surgery. You should report 461.9 (Acute sinusitis, unspecified) as the diagnostic code for the acute sinusitis.

Note: Per Section 4824.A of the Medicare Carriers Manual, you shouldn't use modifier 24 for any "medical management" related to a surgical procedure. You can only use modifier 24 during the hospitalization when the care is related to immunosuppression management or critical care of a burn or trauma patient. Otherwise, you should only report separately identifiable E/M services during the postoperative period after the patient is discharged from the hospital, and the physician then encounters the patient during an office visit or a subsequent hospitalization unrelated to the original surgery.