Wiki Mod -25 with an ED visit

[pmogel]

We do coding and billing for an ED group. We are having a difference of opinion on when it is appropriate to append modifier -25 to an ED visit when the physician performs a procedure such as a laceration repair (12001)and are looking for an outside opinion.

Because of the nature of their practice, each patient and/or patient condition/complaint is new to the physician. He/she has to perform an E&M service that includes all the key elements in order to come to a decision on a treatment plan and procedure. In my opinion, this supports adding modifier -25 to the E&M and billing the E&M separately each time a procedure is performed in the same ED visit. Also, my interpretation of the modifier and guidelines is that a separate diagnosis is not necessary.

What are others opinions?

Thanks,
Patty Mogel, CPC
Scottsdale, AZ

 

[OCD_coder]

In order to support a separate E&M, think of it as beyond a brief E&M service. The E&M must be significant and separate from the minor procedure. Minor procedures have a brief E&M services included as part of the global package. The decision to perform the minor procedure is inclusive of the procedure per Medicare rules Chapter 1 of the NCCI Coding Guidelines. Some carriers have exempted New and ER CPT codes specifically, Palmetto is one.

Example #1
Patient presents with a laceration of the palm of the hand after cutting vegetables at home. Patient has no other complaints. An expanded problem focused history and exam are performed, no additional workup is needed or ordered. Simple repair of palm of hand performed.
Answer: A significant, separate E&M was not performed and documented; only bill the lac repair.

Example #2
Patient presents with an occipital headache and a detailed history and exam are performed and a CT scan is ordered and labs by the ER physician to rule out etiology for the headache. An injection of the occipital nerve was performed.
Answer: Both the E&M and procedure are billable with a modifier 25 as their was a significant workup utilized to assess the problem prior to performing the procedure.

These are simplified examples for forum purposes only. Each encounter is going to have to be assessed for potential E&M work by the provider.

 

[pmogel]

Thank you for your input. I understand your point in #1.

My question, with this type of scenario, is wouldn't it be considered appropriate (and medically necessary) to perform an evaluation of the wound, check for neurovascular or other damage due to the injury and then order the type of closure to be performed? Then, wouldn't it be appropriate, again in this scenario, to bill the ED visit (level 1 or 2) separately with modifier -25? The patient, in most cases, is unknown to the physician in the ED which would make the visit "new to the physician/new condition or complaint". Granted, the level of medical decision making would be low.

 

[jimbo1231]

25 Modifier

Patty,

This is the long time debate between the ED specialty industry and I'd say the more general coding industry. I come from the ED industry and the approach is pretty much what you described in your last post. The thinking is that every patient is essentially new and unknown to the ED provider. Typically at least a 99282 E&M is coded in addtion to the procedure. Of course the documentation and medical neccesity have to be there. But the ED industry argument has been that the examination is necessary and justified due to the nature of ED visits.
Having said that I will say that overuse of the 25 is always under scrutiny by the Feds. And there might come a time when they take a hard look at this approach. But right now I think they are busy retracting their guaruntees of a 10/1/14 ICD-10 deadline!

Jim S.