Advanced Search

Urology Coding Alert

Modifier -25 Rules Differ for CPT, Private Payers and Medicare

Published on Mon Apr 01, 2002

CPT Codes says modifier -25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) can be used to obtain payment for a separately identifiable E/M service provided at the same encounter as a minor procedure. Although many private payers require two diagnoses with modifier -25, Medicare allows the same diagnosis code to be used.
 
But Medicare is trying to control the use of modifier -25: Recall the massive edits of October 2000, rescinded in the next version of Correct Coding Initiative (CCI), which bundled numerous procedures with E/M services. After that, CMS announced that it would educate providers about the correct use of modifier -25. Since then, however, the CCI Edits contractor has changed and the nationwide education on modifier -25 has not occurred.
 
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. Watch for signs that your carrier is scrutinizing modifier -25, perhaps with the aim of conducting its own provider education. 
 
For example, Administar Federal, which covers Indiana and Kentucky, posted a notice on its Web site Jan. 29, 2002:
 
The Carrier has learned that modifier -25 is being inappropriately appended to E/M codes that are not "separately identifiable" from the minor surgical procedure performed on the same day. The narrative definition for modifier -25 is as follows: "Significant, separately identifiable evaluation and management service by the same physician on the same day as a minor procedure." In order to be separately payable, any E/M service performed above and beyond the minor procedure must meet medical necessity requirements, e.g., must not represent a screening examination. Once medical necessity is established, the service must also represent a separate issue or condition from the minor procedure in order for modifier -25 to be used appropriately. The fee for surgical procedure codes includes payment for preoperative and postoperative services. Therefore, a duplicate payment would result if an E/M service is routinely billed during the same encounter as a minor procedure, by attaching modifier -25 to an E/M code when that service is not separately identifiable from the minor procedure done the same day.

The announcement does not include the part of the CPT modifier -25 definition that specifically allows there to be only one problem: "The E/M service may be prompted by the symptom or condition for which the procedure and/or service was provided. As such, different diagnoses are not required for reporting of the E/M services on the same date."
 
When you bill an E/M service with a minor procedure, both the service and procedure must be medically necessary. This means the E/M service must not be a screening examination, notes Michael A. Ferragamo Jr., MD, FACS, clinical assistant professor of urology at the State University of New York, Stony Brook. "Urologists rarely perform a screening or preventive examination, as usually performed by a patient's family physician," he says. However, in everyday urological practice, E/M services are frequently provided in the office with a minor surgical service. "Many of these E/M services are medically necessary and should be paid," he says. A full understanding of the rules and use of modifier -25 is mandatory to bill properly and receive appropriate reimbursement.

Cystoscopy

Cystoscopy (52000, Cystourethroscopy [separate procedure]) is likely to present the bulk of problems with modifier -25 for urologists. For example, a patient presenting with hematuria requires not only a cystoscopy but also a fairly detailed history and physical to determine the appropriate course of treatment, says Sandy Page, CPC, CCS-P, co-owner of Medical Practice Support Services, a coding, billing and compliance consultancy based in Denver. Blood in the urine can have many causes, including a urinary tract infection, stones or tumors. "The doctor has to receive consideration for ruling out these conditions and for managing the problem," Page says. 

Different Diagnosis

Although a different diagnosis is not required to bill Medicare for an E/M service and a minor procedure, a separate issue or condition is required, Ferragamo explains. For example, a urologist sees an established patient for an enlarged prostate. The patient is doing well on medication. The urologist renews his prescription but on a urinalysis discovers microhematuria and decides to perform a cystoscopic examination. Report the office visit (99211-99215) with modifier -25 appended linked to 600.0 (Hypertrophy [benign] of prostate), and 52000 with 599.7 (Hematuria). Both services are medically necessary and should be paid fully with no reduction.
 
In another example, a urologist is consulted and sees an 80-year-old male with an elevated PSA. He discovers a hard prostate and a paraphimosis, which he immediately reduces. Bill for the consult 9924x-25, with the diagnosis 790.93 (Elevated prostate specific antigen, [PSA]). For the reduction of the paraphimosis, use 54450 (Foreskin manipulation including lysis of preputial adhesions and stretching) with 605 (Redundant prepuce and phimosis). Both are necessary, separately identifiable, and fully payable services.
 
In another example, a urologist performs a follow-up cystoscopic exam six months after a bladder tumor resection (52224-52240) and finds a recurrence. After the examination, he discusses further care face-to-face with the patient for 15 minutes. Code solely by time for the face-to-face discussion. Use 99213-25 with 188.x (Malignant neoplasm of bladder). Code 52000 with V10.51 (Personal history of malignant neoplasm; bladder). Again, these are two separately identifiable services, both payable at full fee.

Same Diagnosis

When billing for an E/M service and a minor procedure when the diagnosis is the same, consider the CPT definition of modifier -25, which states that two diagnoses are not required and also that the E/M service may be "prompted" by the same condition that prompted the minor procedure.
 
For example, a urologist evaluates an established Medicare patient for gross hematuria. The hematuria prompts an evaluation (E/M) and a procedure (cystoscopy). Bill the office visit (99211-99215) with modifier -25 appended, and 52000 with the same diagnosis gross hematuria (599.89, Other specified disorders of urinary tract). "That's the CPT rule, and Medicare carriers should follow it," Ferragamo says.
 
In another example, a urologist is consulted in the hospital to see a 75-year-old male unable to void. The urologist finds a distended bladder and urinary retention. He places a Foley catheter for drainage. Report 9925x-25 and 53670* (Catheterization, urethra; simple), with the diagnosis of urinary retention (788.20, Retention of urine, unspecified) for both codes. The consultation and the procedure are payable with the same diagnosis.
 
In another example, a 65-year-old male is examined because of impotence. An injection of the corpora with vasoactive drugs is done for further diagnosis. Code the visit (99211-99215) with modifier -25 appended, and the injection (54235, Injection of corpora cavernosa with pharmacologic agent[s] [e.g., papaverine, phentolamine]) with 607.84 (Impotence of organic origin). The symptom of impotence prompted the examination and injection procedure, Ferragamo notes, and both should be paid.

When Not to Use Modifier -25

The examination and the procedure must be separate. Do not bill an E/M with every procedure because the E/M may be included in the preoperative and postoperative evaluations for minor procedures.
 
If no postprocedure diagnosis exists, it may be hard to justify modifier -25. For example, if a patient has hematuria and the urologist performs an examination and a cystoscopy and finds nothing wrong, it would be difficult to justify billing for the E/M service, says Morgan Hause, CCS, CCS-P, coding specialist for Urology of Indiana in Indianapolis. "Bill only for the cystoscopy," says Hause, whose carrier is Administar. 
 
Do not bill an E/M service if the procedure had previously been scheduled at an initial or past E/M service and the present office visit is strictly for the minor procedure, such as a cystoscopy. For example, a urologist examines a patient and schedules a cystoscopic examination for the next day. Do not charge another E/M service on the day of the cystoscopy; bill only for the cystoscopy. Bill for the past E/M service the day before, however.
 
The record must document and support the need for a separate and significant E/M service beyond the normal preoperative and postoperative service for that procedure. Do not use modifier -25 to report an E/M service that results only in the decision to perform minor surgery. When you bill an E/M service, documentation must clearly define the independent medical necessity for the service.
 
A classic example of when not to use an E/M with a minor procedure is a laceration repair. If a patient sustains a laceration of the skin and requires suturing by the physician, under these circumstances alone no separate E/M service is warranted, Ferragamo says. If, however, the laceration is such that peripheral nerves need to be checked for injury, that examination warrants a separate E/M service. 
 
Finally, do not use modifier -25 to report an E/M service that resulted in a decision to perform major surgery. Use modifier -57 (Decision for surgery) instead.

Private Payers

Private payers may have different rules than Medicare based on their interpretation of CPT. For payment, most commercial carriers require a different diagnosis for the E/M service and the minor procedure. Many do not recognize modifier -25 but will accept modifier -57 for payment with a minor procedure, even though this is not proper coding according to CPT.
 
For example, when the payer is not Medicare, if hematuria prompts the E/M service and a cystoscopy, report the postprocedure diagnosis for the cystoscopy such as bladder stone (594.1) or bladder tumor (188.x) and the hematuria for the E/M service, Ferragamo recommends.
 
In the example of the patient in urinary retention, for commercial payers, report the visit based on the physical findings an enlarged prostate (600.0) and link the placement of the catheter to urinary retention (788.20). 

Therapeutic Versus Diagnostic

Many commercial carriers deny all E/M services when performed on the same day with any surgical procedure. This may be erroneous and contrary to the payers' own guidelines. For example, Vytra Health Plan (based in Melville, N.Y.) denied all such E/M services. However, review of their guidelines revealed that payment would be made if the procedure were strictly diagnostic. (From the Vytra handbook: When a therapeutic procedure is performed during an office visit, the office visit is included in the reimbursement for the surgery; if the procedure is diagnostic, both charges are allowable.) "When it was called to their attention that cystoscopy alone is always diagnostic and not therapeutic, E/M services with cystoscopy were subsequently paid," Ferragamo says.

Preoperative and Postoperative Care

Starred procedures in CPT do not include preoperative and postoperative work, meaning that an E/M code can be billed in addition, with modifier -25, if a separately identifiable service is rendered and postoperative work can also be individually billed. However, Medicare doesn't recognize starred procedures, Page says, noting that the stars are purely for CPT. Some private payers pay attention to the stars.
 
For example, some private payers will pay for an E/M and treatment of a venereal wart (078.19, Other specified viral warts; 54050*, Destruction of lesion[s], penis [e.g., condyloma, papilloma, molluscum contagiosum, herpetic vesicle], simple; chemical or 54055*, electrodesiccation; and 99211-99215 with modifier -25) because that is a starred procedure, indicating that the service includes the surgical procedure only. Follow CPT guidelines when in doubt.

How to Comply with Carrier Requests

Coders should review with their physicians the common portions of preoperative care done for a procedure. "If there is something done for every single cystoscopy, that thing is included in the code," Page says. "You can't charge a separate E/M for it." Back out of the level-of-service of E/M the portion that is directly related to the procedure, Page says. Include this protocol in the coders' notebook for your practice, so coders can refer to it when reviewing documentation.
 
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, which included a reference to the upcoming CCI bundling edits, says 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."
 
But exactly what that inherent evaluative component consists of is not spelled out. "It's a judgment call," Ferragamo says. "The preoperative work for a cystoscopy may include a discussion about the procedure with the patient, obtaining consent, and probably a limited history and physical examination noting any allergies, medications, and checking the vital signs before the procedure," he says. "The postoperative work would be explaining the postoperative orders, ambulation restrictions, and dietary instructions." Also, telling the patient what was found is part of the postoperative work. Coordinating further care and counseling the patient on treatments is not part of the postoperative care, Ferragamo says.
 
Carriers need to give clear directives to physicians, Page says: "They need to go beyond what Administar did, which is basically to say physicians are on their own." That may save the program money, but it doesn't necessarily fulfill the mandate of a Medicare carrier, which is to pay for medically necessary services. "Carriers need to give guidance to providers, indicating what they need to document."
 
The problem, Hause says, is that Medicare does not spell out exactly what the E/M component of a procedure is. And in fact, the relative value units for many of these procedures were established before the E/M guidelines.
 
In a case in which requirements are not clearly disclosed to providers, a hearing would probably result in a favorable ruling for the urologist. But the provider would have to keep going back for each denied cystoscopy/E/M combination, which would be a waste of the provider's time and the Medicare program's money.

Other Articles in this issue of

Urology Coding Alert

View All