Urology Coding Alert

Plus: How to get a copy of our easy-to-use appeal letter

When you need to report an appropriate E/M service that an insurer normally bundles into a procedure, you need modifier -25. Follow these three steps to learn when - and when not - to use the modifier, and how to win an appeal if a carrier denies your claim.

1. Know the Right Time to Code Injections and E/Ms

In some circumstances, your urologist can bill for both an injection and an office visit, even though Medicare may have bundled these services in the past.
 
Example: A prostate cancer patient comes in for his regular Lupron injection.
 
How you should code: For the injection, you could report G0356 (Hormonal antineoplastic), a new injection code for 2005, along with the appropriate E/M code (for example, CPT 99203 , Office or other outpatient visit for the E/M of a new patient ...), says Lisa Dangle, CPC, office manager for Executive Men's Health in Tucson, Ariz.
 
"Typically, patients don't come in just for their Lupron," Dangle says. The urologist will usually also provide E/M services such as review of systems, checking the prostate and going over the PSA results with the patients, she says.
 
Be sure you 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 the E/M to indicate a separate service, says April Borgstedt, CPC, a coding specialist and president of Working for You Consulting in Broken Arrow, Okla.
 
Disaster averted: Although to remain compliant most carriers now accept G0351 (Therapeutic or diagnostic injection [specify substance or drug]; subcutaneous or intramuscular), private carriers may occasionally continue to request CPT injection code 90782 (Therapeutic, prophylactic or diagnostic injection [specify material injected]; subcutaneous or intramuscular).
 
Remember that Medicare no longer accepts this code. Ask your private payer for its injection and modifier -25 policies. In 2005 Medicare will reimburse for the injection code G0351 and an E/M service when performed on the same encounter.
 
Check Your ICD-9 Codes: Before you separate out the E/M with modifier -25, be sure the physician performed an exam that will satisfy coding and medical-necessity guidelines, Borgstedt adds.
 
For example, if the patient is new to your office, your urologist's E/M service should meet all three key elements: history, exam and medical decision-making.
 
In addition, link the appropriate ICD-9 Codes to the procedures and E/M. In the above example, link the patient's complaint of impotence (607.84, Impotence of organic origin) to the E/M service. Link ICD-9 code 257.2 (Other testicular hypofunction [testicular hypogonadism]) to the injection code G0351.
 
Heads-up: Coding guidelines and insurer's policies may not require that you use different diagnosis codes for the procedure and E/M when you append modifier -25, but doing so increases your chances of getting paid with some carriers, Borgstedt says.
 
Special note: Private insurers often require a separate condition or reason for the E/M service. But make sure you don't artificially come up with diagnosis codes to support the separate E/M charge, says Marcella Bucknam, CPC, CCS, CPC-H, CCS-P, HIM program coordinator at Clarkson College in Omaha, Neb. The medical documentation should always support what the physician bills and the codes you use, she says.

2. Master Varying Policies for Ancillary Services

When the urologist performs an office visit and then also provides an ancillary service, such as a urinalysis to determine a diagnosis and treatment plan, you typically don't need to use modifier -25 to separate the E/M service, Borgstedt says.
 
Example: Along with an exam, the urologist or his nurse performs a urinalysis, which is an ancillary service, for a patient with a suspected urinary tract infection.
 
In this case, you could report the appropriate E/M (such as, 99212, Office or other outpatient visit for the E/M of an established patient ...) along with 81002 (Urinalysis, by dip stick or tablet reagent for bilirubin, glucose, hemoglobin, ketones, leukocytes, nitrite, pH, protein, specific gravity, urobilinogen, any number of these constituents; non-automated, without microscopy) without using modifier -25.
 
Quick tip: You should only use modifier -25 to unbundle an E/M service provided at the same time as a procedure with a 0- or 10-day global, Borgstedt says.
 
Watch out: Not all private insurance companies follow CPT coding guidelines, Bucknam says. This means if an insurer requires that you attach modifier -25 to any E/M billed on the same day as a lab or x-ray, you should do it. For instance, some Medicare and private carriers still require you to append modifier -25 to an E/M service when you bill it with a sonographic determination of post-voiding residual urine. Since CPT code 51798 (Measurement of post-voiding residual urine and/or bladder capacity by ultrasound, non-imaging) is a radiological procedure, you would normally not need to modify 51798.
 
Handy tool: If your office deals with several different commercial carriers, you're also probably dealing with several different sets of coding policies. To keep track of these policies, develop a chart that links each of the commercial insurance companies to their respective policies on modifiers for quick, easy use, Bucknam says.

3. Use Our Appeal Letter to Fight Rejections

If you think your insurance carrier has unfairly denied your modifier -25 claim and you want to appeal, you need a tried-and-true appeal letter to get your deserved payment.
 
What to do: Try one of Urology Coding Alert's templates for appealing modifier -25 denials. Simply send an e-mail to jerrys@eliresearch.com for a free template.