Wiki -25...Diagnosis driven or documentation driven...

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TCameron76

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So, here's the situation...doctor sees a patient with chronic COPD. Patient comes in with probable sinus infection and bronchospasm and is all over miserable, and it is exacerbating the COPD. Doc puts her on steroids and amoxicillin n the plan. He also gave her a nebulizer during the visit.

Now, here's the kicker...in the assessment, the doctor mentions NOTHING about any URI or sinus infection or anything. Just exacerbation of COPD. Literally the ONLY diagnosis listed.

Would you give him the -25 modifier on the 99213 for the nebulizer since the diagnosis is only for COPD, which is a chronic and ongoing condition?

Let me hear some thoughts!

Thanks!
 
The use of the 25 modifier is driven by documentation. The documentation must be over above and beyond what is need to perform the procedure and yet still relevant to the presenting problem. So take the documentation and anything that is an inherent part of the assessment of the patient needed to administer the treatment, cross it out and then with what is left over, can you find a visit level. If you can then is significant and the 25 is warranted.
 
Agree, in fact the CMS guidelines, and most payer guidelines, specifically state that a different diagnosis is not required. From the Medicare Claims Processing Manual, Chapter 12, under Drug Administration Services and E/M Visits Billed on Same Day of Service: "when a medically necessary, significant and separately identifiable E/M service (which meets a higher complexity level than CPT code 99211) is performed, in addition to one of these drug administration services, the appropriate E/M CPT code should be reported with modifier -25. Documentation should support the level of E/M service billed. For an E/M service provided on the same day, a different diagnosis is not required."

In your example above, it's pretty clear that the MDM work of evaluating the patient for the exacerbation and prescribing the steroids and antibiotics is not part of the routine pre- and post-procedural work of a nebulizer treatment, so there's very little doubt in my mind that a modifier would be supported in this instance, provided the documentation supports the level.
 
completeness though....

I guess basically in my mind "documentation" includes the assessment portion and should report COMPLETELY any and all conditions assessed during that visit. I just think it is poor practice to not include the obvious respiratory illness in the diagnoses if for nothing more than completeness sake in the record. Also, diagnoses drive a lot of the other payments in the Medicare world, so I don't understand why it wouldn't play a role here...I'm not yelling at the messenger, it just makes me wonder sometimes....
 
I am not sure what you are meaning. Of course the documentation should report the diagnosis, and the assessment that of it, we are just saying that documentation is a necessary part of the treatment rendered and is not separately reported. If an exam of other areas is performed it must be relevant not just check marks indications normal and negative. When you say not include the obvious respiratory illness in the diagnosis, I am unclear to what you mean. If the respiratory illness is documented of course we include it. In your example you stated it was not documented, or did you mean it just was not coded by the doctor? You cannot code what the provider does not document, however if it is documented in that encounter note the yes we code it.
 
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TCameron76 said:
I guess basically in my mind "documentation" includes the assessment portion and should report COMPLETELY any and all conditions assessed during that visit. I just think it is poor practice to not include the obvious respiratory illness in the diagnoses if for nothing more than completeness sake in the record. Also, diagnoses drive a lot of the other payments in the Medicare world, so I don't understand why it wouldn't play a role here...I'm not yelling at the messenger, it just makes me wonder sometimes....
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If I'm understanding you correctly, I think you're really talking about a clinical question here rather than coding - you may have clinical training that makes a respiratory illness seem obvious here, but if the provider did not document it, the coder will not code it and normally isn't responsible for identifying that the provider omitted a piece of clinical information in error. If it you're confident it is an error, it could certainly be an area for discussion with the provider, but wouldn't change the coding which is still based on what was documented. This kind of feedback to providers can certainly be of value, but really your employer really should be the one to give you guidance on the degree to which you bring these things to the provider's attention for review.

Whether or not the documentation completely and accurately reflects the clinical status of the patient requires a certain degree of clinical training, so there is a whole training and certification process, Clinical Documentation Improvement (CDI) which sort of merges coding and nursing training, for just that. As coders, we just follow the guidelines to represent with codes what was documented, and occasionally will query a provider if there is an obvious error or other omission that makes it impossible to accurately code. CDI seeks to do what you're talking about, to review records not just for purposes of comparing the documentation with the codes for accuracy, but to also evaluate whether or not the provider is capturing essential clinical information in their documentation so that when the codes are generated there is the optimal representation of the diseases that are being managed. There's some grey area between coding and CDI of course, since almost everyone trained in coding has some clinical knowledge, but I think it's still important to keep in mind the distinction between these areas.
 
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When I went back and looked at what was written again, you stated Probable Sinus infection and bronchospasm which are not diagnosis we can code as they have not been rendered. However it could be that after exam and assessment the provider did determine that it was just COPD exacerbated, I would use this information to drive the use of the 25 modifier because he did need to assess for the probability of the other possible diagnosis and then determined it was COPD exacerbated and performed the treatment.
 
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