Urology Coding Alert

Make sure you understand modifier -25

Yes, modifier -25 will get you reimbursed for E/M services performed at the same patient encounter as other procedures. But can you bill for as many E/M procedures as the day will allow? Before you start fantasizing about spending all that extra income, repeat after me: "separately identifiable," "separately identifiable."
 
A patient presents with torsion of testis (608.2), requiring a repair (CPT 54600 , Reduction of torsion of testis, surgical, with or without fixation of contralateral testis). During the procedure, concerns are raised about testicular cancer because a lump is present. The physician may bill for a separate E/M service for the procedure and a separate E/M for the cancer with modifier -25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service).
 
Use of modifier -25 rests on how you - and more important, carriers - define the term "separately identifiable." Some carriers are clarifying what they mean by separately identifiable, which requires great care when you decide whether to bill an E/M visit with a minor procedure.

Big Brother Is Watching

Care in this area is very important right now. The Office of the Inspector General of the Department of Health and Human Services is particularly interested in E/M procedures in calendar year 2003. According to the OIG's Fiscal Year Work Plan (available at www.oig.hhs.gov/publications/docs/workplan/2003/2-CMS%20FY03.pdf), the OIG is now "assessing the adequacy of controls to identify physicians with aberrant coding patterns, specifically coding disproportionately high volumes of high-level evaluation and management codes that result in greater Medicare reimbursement."
 
The rules: CMS stated in the Nov. 2, 1999, fee schedule announcement in the Federal Register that "every procedure has an inherent E/M component." This announcement says that the "significant, separately identifiable service would need to be documented in the medical record" whenever using modifier -25. "In other words, we want to prevent the practice of physicians reporting an E/M service code for the inherent evaluative component of the procedure itself."

'It's a Judgment Call'

But exactly what that inherent evaluative component consists of is not spelled out. "It's a judgment call," says  Michael A. Ferragamo Jr., MD, FACS, Clinical Assistant Professor of Urology, State University of New York, Stony Brook, New York.
 
"Modifier -25 says the urologist is doing a significant, separately identifiable service E/M on the same day he does a procedure," he says. "Modifier -25 gets attached to the E/M service, not the surgical service. It goes on either a 0-day global or 10-day global procedure performed on the same day as an E/M service is performed."
 
Kimberly Hodges, CPC, an office manager at a practice in Florida, says she uses modifier -25 often, usually when her urologist performs a procedure on the same day that he performs an E/M service.
 
"Because we don't do our cystoscopies in the offices, we might have a patient who comes in here with gross hematuria and our doctor evaluates him; therefore, he has to put the modifier on the E/M code, and then we will take him over to the hospital and do a cysto on him as an outpatient. That way we get paid for both procedures."
 
There are carrier and local problems to deal with as well. "Aetna and Cigna are really bad," Hodges says. "They don't like to pay for dilations on the same day you do an E/M code. I've written appeal letters to them and have never gotten through. They don't really follow the CPT guidelines; they follow their own guidelines."
 
"If you do female dilations (53660-53661) or male dilations (53620-53621) in the office," Hodges adds, "they don't want to pay for an E/M code even with modifier -25 appended. Medicare is usually never a problem. Blue Cross usually always pay too." Coders would be wise to keep up-to-date on exceptions by certain carriers or in certain states.
 
"Modifier -25 is the most-used and most-abused modifier in coding," Ferragamo says. And Medicare is keeping an eye on its use. For Medicare (and many other private carriers and HMOs), use modifier -25 in the following three clinical scenarios:
 
When there are two co-existing unrelated and separate problems, one evaluated by an E/M service, and the other evaluated or treated by a minor surgical procedure; when one problem, finding or complaint "prompts" both an E/M service and also a minor surgical procedure; and when counseling and coordination of care occurs on the same day usually after and in association with a minor surgical procedure.

Test Yourself

Try your hand at determining when you can separately report an E/M and a minor procedure the urologist performs during the same patient encounter using the following scenarios.

Scenario 1: An established patient presents for a follow-up visit for symptomatic benign prostatic  hyperplasia (BPH), 600.0. The urologist performs a level-two E/M evaluation and renews his prescription for an alpha-blocker. As part of the evaluation, the physician performs a urinalysis (81000) and detects microhematuria (599.7). To further evaluate the microhematuria, he performs a cystoscopic examination (52000, Cystourethroscopy [separate procedure]).
 
Answer: Because the urologist performed the E/M and the cystoscopic examination for two separate but co-existing problems and indications, you should report them separately: 99213-25 (Office or other outpatient visit for the evaluation and management of an established patient ...) and 52000. Don't forget to bill for the urinalysis as well (81000).

Scenario 2: A patient complains of grossly bloody urine. Urinalysis (81000) confirms a diagnosis of gross hematuria (599.89), which prompts you to do both an exam (E/M service) and a cystoscopic examination (52000).
 

Answer: The same diagnosis - gross hematuria - has prompted an E/M service and a surgical service, cystoscopy. Append modifier -25 to the E/M service. Code 9921x-25 and 52000.
 
You should be paid fully for both by Medicare. But Ferragamo says, "Many private carriers and HMOS will not reimburse for both an E/M service and a cystoscopy at the same time, even if all the rules are satisfied."
 
Some will pay if you give two separate diagnoses. Diagnosis one is gross hematuria (599.89) for the E/M code, and diagnosis two is the postoperative diagnosis, that is, whatever is found on the cystoscopic examination: bladder tumor (188.x, Malignant neoplasm of bladder), bladder stones (594.1) or hemorrhagic cystitis (595.9) for the cystoscopy code.

Scenario 3: An established patient has a follow-up surveillance cystoscopy (52000) following removal of a bladder tumor (52234, Cystourethroscopy, with fulguration  [including cryosurgery or laser surgery] and/or resection of; SMALL bladder tumor[s] [0.5 to 2.0 cm]).
 
Answer: If the cystoscopy reveals no tumor recurrence, only charge for the cystoscopy (52000) with the diagnosis of V10.51 (Personal history of malignant neoplasm; bladder). Do not bill an E/M service here unless you have provided another service such as an examination and discussion with the patient concerning his other problem, e.g., impotence (607.84, Organic impotence).
 
If your examination does reveal recurrent bladder tumor, and after the procedure you counsel the patient and coordinate his continued care, bill an E/M service based solely on the time spent with the patient.
 
As long as 50 percent of the encounter time is spent face-to-face with the patient, a separate E/M charge can be made. In this case example, all the time the urologist spent with the patient after the cystoscopic examination involved counseling and coordinating care.
     
You must have documentation of what was discussed in the medical records, but it may be short and concise. Use 52000 (with diagnosis V10.51) and 9921x-25 (based on time and linked to the diagnosis of bladder tumor 188.x, Malignant neoplasm of bladder). The following "time spent" correlates with specific E/M services for the established patient: