Urology Coding Alert

 A new CMS transmittal may mean modifier 25 claims will be targeted

Determining when to append modifier 25 is already difficult -- and thanks to a new transmittal from the Centers for Medicare & Medicaid Services, your modifier 25 claims may be even more of a hassle. Now's the time to sit up and pay attention to make sure your physician's documentation supports modifier 25.

Take Note of 3 Key Points

Your documentation supporting the use of modifier 25  (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) will be under heavy scrutiny soon, judging from Transmittal 954, issued May 19 by CMS.
 
Clarification 1: CMS has added the word "usual," so the guidelines for modifier 25 now read: "a significant, separately identifiable E/M service that is above and beyond the usual pre- and postoperative work for the service." The addition is just meant to emphasize that any extra E/M service must be "above and beyond" the typical pre-op or post-op work, says Quinten Buechner with ProActive Consultants in Cumberland, Wis.
 
Clarification 2: Transmittal 954 clarifies and reemphasizes that you don't need a different diagnosis for the E/M service and surgery to be able to use modifier 25. Remember, however, that many private carriers demand separate diagnoses if you expect them to pay for the E/M service as well as the procedure.
 
Clarification 3: You'll now also need to make sure that you have appropriate documentation that proves the medical necessity of the separate same-day E/M service your urologist provided. You don't need to submit this documentation with the claim, but it must be available upon request.

Stress 'Significance' in Documentation

The guidelines for using modifier 25 haven't actually changed, says Stacie L. Buck, RHIA, CCS-P, LHRM, vice president of Southeast Radiology Management in Stuart, Fla. "CMS is issuing clarification in light of the findings in the OIG's report on modifier 25." The Office of Inspector General found a 35 percent error rate for modifier 25 -- and $538 million in improper payments -- in its sample of claims from 2003.
 
But it's safe to say your modifier claims will be under more scrutiny. "I strongly believe that providers will see more and more claims with 25 subjected to pre- and post- payment review because of the OIG findings," Buck adds.
 
Be proactive: All procedures, from simple injections to common diagnostic tests, include an "inherent" E/M component, according to CMS guidelines. Therefore, any E/M service you report separately must go "above and beyond" the minimal evaluation and management that normally accompanies such a procedure.
 
When you're considering whether you should append modifier 25 to an E/M service code when your urologist performs an E/M service and another procedure or service, follow three tips:

 • Make sure 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.
 • Focus on compiling complete documentation of both the procedure and the separate E/M.
 • Don't append modifier 25 if an E/M is the only service your physician provides the patient that day.

Best practice: Ask your urologist to document the E/M and the procedure in separate paragraphs or even on separate pages in the medical report so you can easily identify their separate nature. "Physicians and coders need to make sure that the documentation clearly supports both services and that all guidelines are followed," Buck says.
 
Bottom line: If your urologist performs a separately identifiable service or procedure along with an E/M service, report both services and append modifier 25 to the E/M code. If the physician plans beforehand, at a previous patient encounter, to do a procedure on another day or encounter and on that day does a limited pre-op evaluation, just prior to surgery, don't bill for a separate E/M.
 
But if your urologist doesn't know whether an operation will be necessary and must rule out other options before surgery, you can bill for the E/M examination performed before the doctor reached the decision to proceed with surgery on that same day.
 
Example 1: Your urologist examines a patient with lower tract obstructive symptoms, finds an enlarged prostate gland and prescribes an alpha blocker. Following his examination, he finds microhematuria on urinalysis, decides to explore this further, and performs a cystoscopic examination.
 
In this case, report both the E/M service with modifier 25 (9921x-25) and the cystoscopic examination (52000, Cystourethroscopy [separate procedure]). The urologist first performed a separate E/M service before he decided on the basis of a urinalysis to do the cystoscopy.
 
Example 2: A patient comes into your office for a scheduled Lupron injection and then also sees your urologist for new symptoms of erectile dysfunction. The urologist then evaluates the patient by performing an updated history and a physical examination, and he decides on treatment for this new symptom and complaint.
 
In this case you can report this separately identifiable E/M service along with the injection code using modifier 25. Report the Lupron injection using 96402 (Chemotherapy administration, subcutaneous or intramuscular; hormonal anti-neoplastic). Then report the appropriate established patient visit code based on the level of service (99212-99215, Office or other outpatient visit for the evaluation and management of an established patient ...) with modifier 25 appended.
 
Pitfall: The exception is 99211 (Office or other outpatient visit for the evaluation and management of an established patient, that may not require the presence of a physician ...), which you cannot ever report with any of the injection codes because the work RVUs are already included and factored in to the injection code. So, if you have an E/M service, higher than a level one, that you can show is separate from the injection service, you may use modifier 25 and report both services.