Radiology Coding Alert

Check your documentation to steer clear of a renewed emphasis on audits

News flash: The Office of Inspector General found a 40 percent error rate for modifier 59 and a 35 percent error rate for modifier 25 when it studied a claims sample. Result: You're going to see a lot more audits.

The OIG is encouraging Part B carriers and Recovery Audit Contractors to monitor claims with these modifiers, which means you can expect to see an increase in both prepayment and postpayment audits for both modifiers.

Protect Your Practice and Toe the Modifier Line

Modifier 59: Keep yourself out of trouble by watching your claims for these red flags related to modifier 59 (Distinct procedural service).

1. Confirm that the procedures you claim are distinct and weren't performed at the same session, same anatomical site, and/or through the same incision.

Example: NCCI Edits bundles 36216 (Selective catheter placement, arterial system; initial second order thoracic or brachiocephalic branch, within a vascular family) into 37215 (Transcatheter placement of intravascular stent[s], cervical carotid artery, percutaneous; with distal embolic protection). You should only unbundle the two, by reporting 37215, 36216-59, if the second order catheter placement is on the opposite side of the neck--not in the carotid on the side where the stent was placed, says Jackie Miller, RHIA, CPC, senior consultant for Coding Strategies Inc. in Powder Springs, Ga.

Helpful: You may be more likely to convince payers if you use separate ICD-9 Codes for the diagnoses behind the separate procedures, says Margie Vaught, a coding consult in Ellensburg, Wash. But only report the diagnosis documented by your physician.

2. Be sure your documentation supports both services.

3. Append modifier 59 to the second code, rather than the primary service code or both codes.

4. Be certain you're reporting the correct code. This may sound obvious, but 7 percent of the incorrect modifier 59 claims the OIG audited used the wrong code.
 
Resource: CMS posted an article on modifier 59 on its Web site. Check it out under "Downloads" at www.cms.hhs.gov/NationalCorrectCodInitEd/01_overview.asp.

Modifier 25: The OIG pointed out three main problems with claims involving modifier 25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service). Here's how to avoid them.

1. Be certain 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.

2. Focus on compiling complete documentation of both the procedure and the separate E/M. 

3. Don't append modifier 25 if an E/M is the only service your physician provides the patient that day.
 
When you're applying modifier 25, you should remember the maxim:

"If you don't have a HEM, you can't bill an E/M," says Laureen Jandroep, director and senior instructor for CRN Institute in Absecon, N.J. "HEM" stands for "history, exam and medical decision-making." All procedures include a mini-E/M visit related to the procedures, but a separate E/M should include its own HEM, Jandroep says.

"When you put the 25 modifier on, you're telling the payer, 'I have documentation to back it up,' " Jandroep says.

Interventional radiology tip: For image guided interventions, you're most likely to use modifier 25 when a patient presents for evaluation of certain signs or symptoms and on the same day, the physician performs a procedure to help establish the diagnosis and/or to resolve the underlying condition.

Example: The radiologist sees an inpatient in consultation for acute ischemia of the foot. The radiologist advises angiography with possible percutaneous intervention. Later that day the patient undergoes angiography and mechanical thrombectomy of the popliteal artery. Report the inpatient consultation (9925x) with modifier 25, as well as the angiogram and thrombectomy, Miller says.

Caution: Don't report a separate E/M for obtaining informed consent and the basic history and physical exam needed for a safe interventional procedure.