Urology Coding Alert

Without excellent documentation from your urologist, you'll be forced to skip separate E/M coding.

If you automatically append modifier 25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) to every E/M service your urologist performs on the same day that he also performs a procedure, you're asking for an audit. Unlock the secrets to legitimate coding and reimbursement for separately identifiable E/M services using modifier 25 with these three guidelines.

1. Ensure Your Urologist Performed a Separate Service

You should use modifier 25 when your urologist's documentation supports that he performed an E/M service that was significant and separately identifiable from the work included in another service or procedure.

When you're reviewing your urologist's documentation you need to be able to clearly identify the separate service before you can append modifier 25. "Look at the documentation and cross out anything that is directly related to the procedure performed," says Judith L. Blaszczyk RN, CPC, ACS-PM, compliance auditor with ACE consulting in Leawood, Kan. "Look then at the remaining documentation to determine if it is indeed significant, separately identifiable and medically necessary," she adds.

Official guidance: CPT's Appendix A states that a significant and separately identifiable service "is defined or substantiated by documentation that satisfies the relevant criteria for the respective E/M service to be reported."

"If coders slow down and take the time to read the definition of use of modifier 25 in their CPT book, we would have less errors," says Jetton Torix, CCS-P, CPC-H, course director of Knowledge Source Seminars in North Port, Fla. and Cross Country Education instructor. "Providers often do not remember that if something has to be done to do the main service, it is considered part of it and not separately billable."

Remember: You can only consider reporting modifier 25 when coding an E/M service. If the procedures you're reporting don't fall under E/M services, it's possible the encounter qualifies for another modifier instead.

Example: Your urologist sees a patient for a previously scheduled cystoscopy to check for recurrent bladder tumors. The cystoscopy returns negative results. After the cystoscopy the patient brings up a new problem, such as erectile dysfunction. Therefore, your urologist performs an examination, discussesthe problem with the patient, and writes a prescription.

Because the erectile dysfunction is a new problem, you can separately report both the E/M service and the cystoscopic examination. You would code 52000 (Cystourethroscopy [separate procedure]) and the appropriate E/M code, such as 99213 (Office or other outpatient visit for the evaluation and management of an established patient ...) with modifier 25 appended. If that same patient had had only the cystoscopic examination and no separate E/M service, then you would not bill a separate office visit code.

Bottom line: "The E/M service must be able to stand on its own as separately identifiable," agrees Suzan Berman CPC, CEMC, CEDC, senior manager of coding education and documentation compliance, in the Physician Services Division at the University of Pittsburgh Medical Center. "You are essentially telling the insurance company: 'During this visit I determined XYZ needed to be done and I happened to have  time to do it that day.' If you can't say this (or something like it) then the E/M service shouldn't be billed."

2. Don't Confuse Modifiers 25 and 57

One of the most common points of confusion is between modifier 25 and modifier 57 (Decision for surgery). You might use either modifier 25 or modifier 57 when your urologist performs a procedure and a distinct E/M service for the same patient on the same day.

The quickest distinction is that you would use modifier 25 for a distinct E/M with a minor procedure performed on the same day, and modifier 57 for a distinct E/M with a major procedure performed on the same day.

How it works: You should only use modifier 25 with procedures that have a 0- or 10-day global period, Berman explains. These kinds of procedures are what Medicare defines as "minor." In contrast, you'll use modifier 57 for procedures with a 90-day global period. Note, however, that some payers are now requesting 57 on 10-day globals, according to Torrix, so check with your individual payers.

Watch out: Some coders view modifier 25 as a "magic bullet" and they always add a 25 modifier to E/Ms done on the same day as a procedure because that is the only way they can get them paid. Don't fall into that trap. "Any practice that applies modifier 25 indiscriminately to their E/Ms will be an outlier to other practices in the volume of claims billed with modifier 25 and will be sending up red flags," Blaszczyk says.

3. Stop Omitting 25 Because of Same Dx

Proper modifier 25 use does not require a different diagnosis code. In fact, the presence of different diagnosis codes attached to the E/M and the procedure does not necessarily support a separately reportable E/M service. Your key to separately reporting the E/M service lies in whether your urologist performed work beyond what is considered to be part of the procedure.

"The guidelines changed years ago that you do not need to have a different diagnosis to use modifier 25," Torrix says. "But it still seems to be easier to get paid if the diagnoses are different," she adds.

How it works: When using modifier 25, the diagnosis associated with the E/M service can be the same as the diagnosis associated with the same-day procedure, or the diagnosis associated  ith the E/M service can be different than the diagnosis associated with the same-day procedure. "The proof [of separately reportable services] is in the documentation of the E/M service," Berman says.

Go to the source: The information about modifier 25 in the CPT manual clearly indicates that you no longer have to have two different diagnosis codes to use the modifier. The CPT manual states: "The E/M service may be prompted by the symptom or condition for which the procedure and/or service.