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Title: Modifier 25 – When to Pick Up the Procedure Session: W

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1 Title: Modifier 25 – When to Pick Up the Procedure Session: W-5-1100
Track x – xxx day – Title: Modifier 25 – When to Pick Up the Procedure Session: W

2 Modifier 25 Defined Significant, separately identifiable E&M service by the same physician on the same day of the procedure or other service. For significant, separately identifiable non-E&M service, see Modifier 59. Medicare designates minor procedures as “all surgeries and endoscopies assigned a 0- or 10-day global surgery period.” In cases where an E&M service is provided and a minor procedure is scheduled for a subsequent day, the appropriate E&M service may be reported for the visit. On the day of the scheduled procedure, only the procedure is coded. An E&M service (e.g., established patient visit) should not be coded on the same day as a previously scheduled procedure. The patient's condition required a significant, identifiable E&M service above and beyond the other service provided (example of “other service” is when you have a preventive medicine encounter with an additional “sick type” issue addressed and worked at the same time) or services beyond the “usual” preoperative and postoperative care associated with the procedure that was performed. These circumstances may be reported by adding the -25 modifier to the appropriate level of the E&M service. If the evaluation and management service is related to the decision to perform a major procedure, a -25 modifier is not appropriate. The correct modifier is modifier -57, decision for surgery. First, the phrase "the patient's condition required" is extremely important. In other words, it was medically necessary for the patient to have these extra services on the same day that another procedure or service was performed. Second, the phrase, "a significant, separately identifiable E&M service above and beyond" the other service provided indicates that this extra service was clearly different from the other procedure or service that was performed. Third, the phrase "services beyond the usual preoperative and postoperative care" associated with the procedure emphasizes the fact that all procedures as defined in the Resource Based Relative Value Scale (RBRVS) system of reimbursement that Medicare uses include a certain amount of preoperative and postoperative care in the reimbursement package. Modifier 25 should be used if extra work beyond the usual is performed. So what is included in the pre and post procedure? In general, these services are limited to assessing the site or the condition of the problem area, explaining the steps in the procedure, and obtaining informed consent. Also, the Centers for Medicare & Medicaid Services (CMS) has clarified that the initial evaluation is always included in the reimbursement for a minor surgical procedure and, therefore, is not separately billable. For a procedure assigned a 0-day global period, preoperative and postoperative visits on the day of the procedure are included in payment for the procedure. For a procedure assigned a 10-day global period, visits on the day of the procedure and within the 10-day period are included in payment for the procedure. Visits provided the day before these minor procedures are not included in the global period and are separately billable, as appropriate. Once again: When the decision to perform a minor procedure is made immediately before it is rendered and a significant, separately identifiable E&M service is not necessary, only the procedure should be reported. *****For example: An established patient who well known to the physician, presents for closure of a simple laceration. Only the appropriate repair code should be reported.

3 Modifier 25 Defined (cont’d)
Modifiers Modifier 25 is appended to the E&M code when a procedure is preformed as well as a separately identifiable E&M. Do not use Modifier 25 with E&Ms done at the same time as laboratory tests (e.g., KOH, wet prep). The key is recognizing when extra work is “significant” and a separate E&M is within acceptable limits to code with the minor procedure. Did the provider perform and document the significant components of a “problem-orientated” E&M service? Could the complaint or problem stand alone for coding purposes? A different diagnosis is not a requirement. Documentation supports work effort above and beyond the standard pre- and postoperative work? ** Different diagnosis is not a requirement. **Documentation is the key to using this modifier. 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. Many times a patient's "Oh, by the way …" comment turns an encounter that was scheduled as a preventive medicine visit or a minor office surgery into something more. The key is recognizing when your extra work is "significant" and, therefore, additionally code-able. CPT does not define "significant," but asking yourself the following questions should lead you to the answer: • Did you perform and document the key components of a problem-oriented E&M service for the complaint or problem? • Could the complaint or problem stand alone as a billable service? • Is there a different diagnosis for this portion of the visit? If the diagnosis will be the same, did you perform extra physician work that went above and beyond the typical pre- or postoperative work associated with the procedure code? If your answers to these questions are yes, then you should report the appropriate E&M code with modifier -25 attached as well as the preventive medicine service code or minor surgical procedure code. TIP: Organize your note so that documentation for the problem-oriented E&M service is separate from documentation for the preventive service or procedure. You may even want to use headers or a phrase such as "A significant, separate E&M service was performed to evaluate … ."

4 National Correct Coding Initiative (NCCI) Edits?
Developed to control improper coding Designed to detect “fragmentation” Identify inappropriate unbundling of comprehensive procedure codes into component parts The NCCI edit manual addresses general coding principles, issues, and policies There are two NCCI edit tables: “Column One/Column Two” and “Mutually Exclusive Edit Table” Modifier 25 may be justified based on documentation HCPCS coding clinic: Issue: 2 Title: Correct coding initiative (CCI) edits Body: The Correct Coding Initiative (CCI) was developed to control improper coding. Many of these edits were designed to detect “fragmentation,” or separate coding of the component parts of a procedure, instead of reporting a single code, which includes the entire procedure. CCI edits help identify inappropriate unbundling of comprehensive procedure codes into component parts. Unbundling is the billing of separate codes for related services when one code includes all related services. The unbundling of procedures will occur at times from a misunderstanding of coding guidelines and instructions. A modifier will permit a claim to bypass correct coding edits. Per NCCI, Chapter 1: There are two NCCI edit tables: “Column One/Column Two Correct Coding Edit Table” and “Mutually Exclusive Edit Table”. Each edit table contains edits which are pairs of HCPCS/CPT codes that in general should not be reported together. Each edit has a column one and column two HCPCS/CPT code. If a provider reports the two codes of an edit pair, the column two code is denied, and the column one code is eligible for payment. However, if it is clinically appropriate to utilize an NCCI-associated modifier, both the column one and column two codes are eligible for payment. Many procedure codes cannot be reported together because they are mutually exclusive of each other. Mutually exclusive procedures cannot reasonably be performed at the same anatomic site or same patient encounter. An example is a service that can be reported as an "initial" service or a "subsequent” service. With the exception of drug administration services, the initial service and subsequent service cannot be reported at the same patient encounter. CPT codes that are mutually exclusive of one another can be identified as code pairs. These code pairs should not be reported together. In order to identify these code pairs, an independent table of mutually exclusive edits has been developed as part of the NCCI. Many edits in the mutually exclusive edit table allow the use of NCCI-associated modifiers.

5 National Correct Coding Initiative (NCCI) Edits?
All procedures are assigned a Global period of 000, 010, 090, XXX, YYY, or ZZZ. The decision to perform a minor surgical procedure is included in the payment for the minor surgical procedure and should not be reported separately as an E&M service. However, a significant and separately identifiable E&M service unrelated to the decision to perform the minor surgical procedure is separately reportable with Modifier 25. Procedures with a global surgery indicator of “XXX” are not covered by these rules. Per NCCI, Chapter 1: All procedures on the Medicare Physician Fee Schedule are assigned a Global period of 000, 010, 090, XXX, YYY, or ZZZ. The global concept does not apply to XXX procedures. The global period for YYY procedures is defined by the Carrier. All procedures with a global period of ZZZ are related to another procedure, and the applicable global period for the ZZZ code is determined by the related procedure. An E&M service is separately reportable on the same date of service as a procedure with a global period of 000, 010, or 090 under limited circumstances. If a procedure has a global period of 000 or 010 days, it is defined as a minor surgical procedure. The decision to perform a minor surgical procedure is included in the payment for the minor surgical procedure and should not be reported separately as an E&M service. However, a significant and separately identifiable E&M service unrelated to the decision to perform the minor surgical procedure is separately reportable with modifier NCCI does contain some edits based on these principles, but the Medicare Carriers have separate edits. Neither the NCCI nor Carriers have all possible edits based on these principles. Procedures with a global surgery indicator of “XXX” are not covered by these rules. Many of these “XXX” procedures are performed by physicians and have inherent pre-procedure, intra-procedure, and post-procedure work usually performed each time the procedure is completed. This work should never be reported as a separate E&M code. Other “XXX” procedures are not usually performed by a physician and have no physician work relative value units associated with them. A physician should never report a separate E&M code with these procedures for the supervision of others performing the procedure or for the interpretation of the procedure. With most “XXX” procedures, the physician may, however, perform a significant and separately identifiable E&M service on the same day of service which may be reported by appending modifier –25 to the E&M code. This E&M service may be related to the same diagnosis necessitating performance of the “XXX” procedure but cannot include any work inherent in the “XXX” procedure, supervision of others performing the “XXX” procedure, or time for interpreting the result of the “XXX” procedure. Appending modifier –25 to a significant, separately identifiable E&M service when performed on the same date of service as an “XXX” procedure is correct coding.

6 Modifier 25 and Preventive Medicine Services
Case # 1 – During a preventive medicine service, a significant problem or abnormality may be identified and may require additional work to perform the key components of a problem-oriented E&M service. Both the appropriate office/outpatient E&M and preventive medicine codes may be reported. Modifier 25 should be appended to the office/outpatient E&M code to indicate that a significant, separately identifiable E&M service was also provided on the same day by the same physician. I am pretty sure this is an area that the we may be missing the boat on. If an abnormality is encountered or a preexisting problem is addressed in the process of performing this preventive medicine evaluation and management service, and if the problem/abnormality is significant enough to require additional work to perform the key components of a problem-oriented E&M service, then the appropriate office/outpatient code should also be reported. Modifier -25 should be added to the office/outpatient code to indicate that a significant, separately identifiable evaluation and management service was provided by the same physician on the same day as the preventive medicine service. The appropriate preventive medicine service is additionally reported. A problem/abnormality encountered in the process of performing the preventive medicine evaluation and management service that does not require additional work and the performance of the key components of a problem-oriented E&M service should not be reported.

7 Modifier 25 and Preventive Medicine Services
Case # 2 – A 33-year-old established female patient presents to the physician's office for her yearly gynecological examination. All elements of the annual physical (history, exam, counseling, etc.) are documented clearly. During the examination, the physician identifies a palpable, solitary lump in the right breast. The physician considers this finding significant enough to require additional work and the performance of the key components of a problem-oriented E&M service. Reference: CPT Assistant, May 2002, Preventive Med Services 99395 would be reported for the preventive medicine visit. The appropriate problem-oriented level of E&M service should be selected based on the key components associated with providing the problem-oriented (lump of the breast) E&M service. For established patients office or other outpatient visits, two of the three key components (history, examination, and medical decision making) must meet or exceed the stated requirements to qualify for a particular level of E&M service. Modifier '-25' would then be appended to the office visit level of service reported, to indicate that a significant, separately identifiable E&M service was provided. The appropriate ICD-9-CM diagnosis codes reported should reflect the yearly gynecological examination provided and associated CPT code The breast lump would be reported with an ICD-9-CM diagnosis code and should be associated with the problem-oriented E&M visit code reported.

8 Modifier 25 and Preventive Medicine Services
Case # 3 – An established 55-year-old male patient presents for his routine annual physical. History includes: hypertension, on beta blocker therapy; DM controlled with sulfonylurea; and chronic stable angina controlled with sublingual nitroglycerin as needed. All elements of the annual physical (history, exam, counseling, etc.) are documented clearly. Furthermore, a specific history is taken and further examination is performed regarding the established diagnoses as listed above. Medical decision making of low to moderate complexity, including counseling about medication and alternatives, a plan for appropriate laboratory work, review of possible medication side effects, and a plan for ongoing management, is made. Reference: CPT Assistant, May 2002, Preventive Med Services; A 55-year-old established male patient presents for periodic preventive medicine reevaluation and management. The patient has established diagnoses of hypertension, on beta blocker therapy, Type II diabetes controlled with sulfonylurea, and chronic stable angina controlled with sublingual nitroglycerin as needed. A comprehensive history and examination are performed as part of the preventive medicine service. The physician counsels the patient regarding diet, exercise, and injury prevention. Risk factors are identified and interventions discussed. Medically appropriate laboratory tests and diagnostic procedures are ordered. Anticipatory guidance counseling/risk factor reduction interventions are covered to the extent that they have not been in previous preventive medicine examinations. Furthermore, a specific history is taken and further examination is performed regarding the established diagnoses as listed above. The physician performs a problem-oriented expanded problem focused history and examination including medication compliance, diet, and stress issues. Expanded problem focused examination is given that includes vital signs, chest and heart examination, check for edema. Medical decision making of low to moderate complexity including counseling about medication and alternatives, a plan for appropriate laboratory work, review of possible medication side effects, and a plan for ongoing management is made. CPT code would be used for the preventive medicine services visit. In addition, the appropriate problem-oriented level of E&M service would be selected based on the key components associated with providing the problem-oriented E&M service.

9 Modifier 25 and Preventive Medicine Services
Case #4 – An established 3-year-old male patient presents for his routine annual physical. An age- and gender-appropriate comprehensive ROS and PFSH are performed, as well as a comprehensive assessment/history of pertinent risk factors. A comprehensive, multi-system exam is performed based on the patient’s age and the risk factors identified. Speech and blood pressure are checked, while growth, development and behavior are also assessed Immunizations are reviewed. Anticipatory guidance is given to the mother regarding prevention of injuries in this age group, good parenting practices, nutrition, discipline, and dental care. Risk factors are identified and interventions discussed. Medically appropriate lab tests are ordered. Reference: CPT Assistant, May 2002, Preventive Med Services; Vignettes continued on next slide.

10 Modifier 25 and Preventive Medicine Services
Continued from slide 7, case #4: The mother describes a two-day history of the child pulling at his right ear, irritable, running a low-grade fever, coughing, and having difficulty sleeping at night. The provider then performed the key components of a problem-oriented E&M service. The problem-oriented E&M service included an EPF history with labored breathing and pain in the respiratory system. The EPF exam included ENT, chest, and hydration status. The MDM was of low complexity, and there were discussions regarding possible need for tonsillectomy & adenoidectomy. Appropriate lab tests were ordered. Antibiotics were prescribed. The physician diagnosed acute OM, acute tonsillitis, and acute adenoiditis. CPT code would be used for the preventive medicine visit. In addition, the appropriate problem-oriented level of E&M service should be selected based on the key components associated with providing the problem-oriented E&M service. Modifier -25 would then be appended to the office visit level of service to indicate that a significant, separately identifiable E&M service was provided. The appropriate ICD-9-CM diagnosis codes reported should also reflect the services provided for the routine infant or child health check for the preventive medicine service provided and associated CPT code The acute otitis media of the right ear would also be reported. These diagnosis codes should be associated with the problem-oriented E&M visit code.

11 Modifier 25 and Preventive Medicine Services
What about a new patient visit with an additional complaint or “sick type” of complaints at the same encounter? If a preventive medicine service ( ) and an office or other outpatient service ( ) are each provided during the same patient encounter to a new patient, is it appropriate to report each evaluation and management (E&M) service as a new patient visit? Or is it appropriate to report the preventive medicine service as a new patient and the acute visit (i.e., office or other outpatient service, ) as an established patient?  Reference: CPT Assistant, October 2006, page 15, Q&A AMA Comment: It is important to first take careful note of the New and Established Patient instructions provided in the E&M services guidelines of CPT. Specifically, the guidelines state: Solely for the purposes of distinguishing between new and established patients, professional services are those face-to-face services rendered by a physician and reported by a specific CPT code(s). A new patient is one who has not received any professional services from the physician or another physician of the same specialty who belongs to the same group practice, within the past three years. An established patient is one who has received professional services from the physician or another physician of the same specialty who belongs to the same group practice, within the past three years. Therefore, if a preventive medicine service and an office or other outpatient service are each provided during the same patient encounter, then it is appropriate to report both E&M services as new patient codes (ie, and , as appropriate), provided the patient meets the requirements of a new patient based upon the previously noted guidelines. *** You would need to add a modifier -25 to the office outpatient E&M ( ).

12 Global Coding and Modifier 25
Section of the MHS coding guidelines state: “Global procedures are similar to bundled procedures. Global surgical packages have one code for all three parts: preoperative services, the procedure, and uncomplicated postoperative care – a package deal. The global package includes low-level patient monitoring and topical anesthesia.” In general, these services are limited to assessing the site or the condition of the problem area, explaining the steps in the procedure, and obtaining informed consent. Also, the Centers for Medicare & Medicaid Services (CMS) have clarified that the initial evaluation is always included in the reimbursement for a minor surgical procedure and, therefore, is not separately billable. So what is included in the pre- and post-procedure? Always keep in mind that all procedures as defined in the Resource Based Relative Value Scale (RBRVS) system of reimbursement that Medicare uses include a certain amount of preoperative and postoperative care in the reimbursement package. The -25 modifier should be used if extra work beyond the usual is performed.

13 Office E&M with a Minor Surgical Procedure Code?
Case # 1 – Patient presents for a scheduled interrogation of their pacemaker. After the interrogation, they see the physician who reviews the results of the interrogation with the patient. The interrogation was normal. An interim history is taken and a brief exam may be performed. The patient is told to return for another interrogation in six months. Case # 2 – Patient presents for a scheduled interrogation of their pacemaker. After the interrogation, they see the physician who reviews the results of the interrogation with the patient. The interrogation was not normal. An interim history is taken and a detailed exam is performed. The patient’s medications are adjusted and the patient is asked to return in six weeks. Case # 1 - Based on CMS interpretation of significant and separate identifiable E&M – this would be Incorrect to use of Modifier – 25. In this case the visit is related to the interrogation and no additional issues or concerns were found or addressed at this visit. The interrogation CPT code is the only thing that should be coded. Case # 2 – The test was abnormal and based on the test the provider had to perform additional history, exam, and MDM elements to treat the patient. The provider documented clearly all elements needed to meet an office E&M code and therefore the provider did meet the criteria for an E&M code with modifier -25, and the interrogation CPT code.

14 Office E&M with a Minor Surgical Procedure Code?
Case # 3 – A new patient was sent to an orthopedic surgeon for a consultation due to pain in the left shoulder for one month. The pain was increasing in intensity and limiting, according to the patient. The physician’s documentation indicated that the left and right shoulders were examined; neurological evaluation of the shoulders and upper extremities/neck were performed, including the performance of a brief range of motion test. A complete x-ray study of the left shoulder was taken and read as normal. The orthopedist determined that the patient had a joint inflammation, and administered a cortisone injection. The documentation information included additional HPI, a ROS check-off list that was left blank, her impression and plan (documentation only indicates that “injection given”). Provider coded: Consultation E&M code with Modifier 25, CPT (x-ray study of shoulder), and CPT (injection, shoulder). Do you agree? I don’t think so. Before we go any further and even begin to calculate an E&M for this one, you can see right away that something is not right here. First - the code sticks out like a flashing neon light in the desert. We do not normally code for x-rays in the clinic setting. There are always a few exceptions to this rule so always refer to the MHS coding guidelines for more details. The radiology department is responsible for reading these films and therefore the radiology department would in turn get credit for the formal reading and interpretation. The only thing you may be able to do on this outpatient office visit is give the provider a bullet for the MDM portion of the E&M code for reading the “wet film” in the clinic. Second – the only documentation for the injection was “injection given”. Let me play devils advocate here for a moment: would you be able to bill for the injection on the grounds of “injection given” as your only documentation for this procedure. Lets take the consultation out of the picture and lets say hypothetically the patient is a well established patient, who is coming in for the injection only. Be honest, could you code for “injection given”? Had the provider’s medical documentation included the name, dosage, and site of the cortisone injection, the cortisone injection would have been ok to code. The provider would code the injection into the joint, and the J code for the supply of the medication as long as it came out of clinic stock. IM injections do not have near the weight that a joint injection would have. We need specific information to code these accurate. For the above scenario, the only thing the provider can code for is the consultation E&M. The code has an RVU weight of That was just eat up by the clinic and not passed on to the recipient of the services rendered due to lack of proper documentation.

15 Office E&M with a Minor Surgical Procedure Code?
Case # 4 – Patient presents to dermatology for a wart treatment on the left hand. The physician evaluates the condition of the patient’s skin where the wart is located, and adjacent and decides to perform a f/u treatment with cryotherapy to the left hand wart area today. Case # 5 – Patient presents to dermatology for a wart treatment. During the exam of the skin on the left hand and arm, the patient also complains of a rash on the back. The physician decides to perform a follow-up treatment today with cryotherapy to the left hand area where the wart is located. The provider continues with a full skin exam of the patient and prescribes the patient a steroidal cream for the rash on the back. Hypothetically lets just say that the proper cryotherapy procedure note is attached to this encounter documentation, and meets all the “documentation rules” for a cryotherapy CPT code. Case # 4 – In this case it is not appropriate to code for an office visit E&M in addition to the wart treatment as the purpose of the visit was to evaluate the need for a wart treatment, and wart treatment was performed and we have a proper note to validate the procedure with. Case # 5 – In this case it would be appropriate to code for the office visit E&M code in addition to the wart treatment. The provider had to evaluate the new problem in addition the return visit for the wart on the left hand. The provider performed enough elements of the E&M for the history, exam, and MDM to validate that this visit qualifies for the procedure CPT code and the E&M code with the modifier -25 appended to the E&M code.

16 Office E&M with a Minor Surgical Procedure Code?
Case # 6 – Ms. Jones has returned for re-evaluation of her heel pain. Ten days prior the doctor told her that she might require a series of three cortisone injections 10 days apart in order to resolve her symptoms. She was given her first injection at that time. During this return visit, she reported that, at first, the right heel hurt, but over the past 4 or 5 days, the pain level had reduced by 60%. The patient pointed to an area of the right heel that was still tender. The site was palpated to isolate the area of maximum pain, and a 2nd injection (3mg) of Celestone Soluspan was administered to the area near the insertion of the plantar fascia. The patient was advised to continue her stretching exercise, and keep her weight-bearing activities to a minimum. Impression: plantar fasciitis, right heel. Return to office in 2 weeks for possible 3rd injection. Case # 6 - Review of this scenario indicates the following: There is no evidence of a separate, significantly identifiable E&M service since: the diagnosis/condition stayed the same; the treatment was pre-scheduled (it was the primary service performed on a patient scheduled to return to the office for f/u care; there was no significant interval history or exam changes, and the f/u treatment remained unchanged. 20550 – RT for the injection, plantar fascia J0702 for the medication

17 Office E&M with a Minor Surgical Procedure Code?
Case # 7 – A 32-year-old female is referred to the ENT provider from her FP (referral order is attached to the end of the note and states to evaluate and treat) due to chronic left ear/jaw pain for 2 years. The ENT provider performs a detailed history, and an expanded problem-focused exam. A diagnostic fiberoptic scope of the nasopharynx area is performed; documentation includes a detailed procedure note and findings. Provider documents: ear pain (possible TMJ), facial paralysis with a history of Bell’s palsy. Two prescriptions are ordered, and an MRI is also ordered for evaluation of the continued ear pain and palsy. The patient is told to follow up in 2 weeks following the MRI for results and options. The ENT provider should report a new patient E&M code based on the documentation. A modifier 25 is not required for this new patient, with the minor procedure (unless payer required). The procedure code would also be coded based on the documentation.

18 Office E&M with a Minor Surgical Procedure Code?
Case # 8 – Tom presents to the clinic for a prescribed insect venom antigen after testing positive on a skin test for “honeybee.” Dr. Blake performed an assessment, to include pertinent history, and noted changes in HPI/ROS since last visit. Documentation indicates the site and amount of drug administered. Tom remained in clinic for 20 minutes following the injection with no adverse reactions noted. Case #9 – Tom mentions to Dr. Blake that he has a new rash on his legs. Dr. Blake evaluates the rash, which is not related to the allergy injection, and performs a history, and examination, and then prescribes a steroid ointment for the rash. 1995 Issue: Summer Pages: 4 Title: Reporting Evaluation and Management Services in Addition to Allergy Immunotherapy or Pulmonary Diagnostic Procedures Case # 8 - If a physician sees a patient for professional services for allergen immunotherapy and provides the allergenic extract, single stinging insect venom, CPT code is reported There would not be an E&M reported with this visit. The injection includes the pre-service, intra-service, and post-service elements and therefore it would be inaccurate to report a separate E&M with this example. Case # 9 - If the physician also evaluates a new rash, unrelated to the allergy injection, on the patients lower extremities and performs a history, an examination, and medical decision making, a separate E&M code can be used based on the level of the three key components. The modifier -25 should be appended to the E&M code.

19 Office E&M with a Minor Surgical Procedure Code?
Case # 9 – A physician examines a patient exhibiting a fever, headache, vomiting, and stiff neck, and performs a spinal tap, as well as the services described in code To report this, the physician appends Modifier 25 to code to indicate that both a significant E&M service and a procedure were performed on a given day. Do you agree? Case # 10 – Can my doctor report an office visit when he performs chiropractic manipulative treatment? Case # Issue: May Pages: 1 Title: Modifiers, Modifiers, Modifiers: A Comprehensive Review Modifier -20, Microsurgery: Illustration of Modifier 25 A physician examines a patient exhibiting a fever, headache, vomiting, and stiff neck, and performs a spinal tap, as well as the services described in code To report this, the physician appends Modifier 25 to code 99214, to indicate that both a significant E&M service and a procedure were performed on a given day. *** If the patient did not have the spinal tap and the provider decided to take the pt to the OR for exploratory surgery, a modifier 25 would not be appropriate. Do not use modifier 25 to report an E&M service that results in a decision to perform surgery, for this circumstance, use modifier 57. Case #10 - Year: 1997 Issue: February Pages: 10 Title: Chiropractic Manipulation (Q&A) Body: Coding Consultation Question - Can my doctor report an office visit when he performs chiropractic manipulative treatment? AMA Comment From a coding perspective, the chiropractic manipulative treatment codes include a pre-manipulation patient assessment. Additional E&M services may be reported separately using the modifier 25 if and only if the patient's condition requires a significant separately identifiable E&M service above and beyond the usual preservice and postservice work associated with the procedure and the key components of the level of E&M service are met.

20 Emergency Department E&M with a Minor Procedure Code?
Transmittal A stated that Medicare required that Modifier 25 “always be appended to the Emergency Department E&M codes when provided...” the Outpatient Code Editor (OCE) only requires the use of Modifier 25 on an E&M code when it is reported with a procedure code that has a status indicator of “S” or “T”. S = Significant procedure, payment allowed under hospital OPPS, but multiple procedure reduction does not apply. T = Surgical service, payment allowed under hospital OPPS. The only services to which the multiple procedure reduction applies. *** The information on this slide is applicable to the ED or OP clinic visits when appropriate. HCPCS Coding Clinic: Issue: 3 Title: Modifier -25: Transmittal A stated that Medicare required that modifier -25 “always be appended to the Emergency Department E&M codes when provided...” the Outpatient Code Editor (OCE) only requires the use of modifier 25 on an E&M code when it is reported with a procedure code that has a status indicator of “S” or “T”. Nevertheless, such an edit does not preclude the reporting of modifier 25 on E&M codes that are reported with procedure codes that are assigned to other than “S” or “T” status indicators, if the procedure meets the definition of “significant, separately identifiable E&M service.” S = Significant procedure, payment allowed under hospital OPPS, but multiple procedure reduction does not apply. T = Surgical service, payment allowed under hospital OPPS. The only services to which the multiple procedure reduction applies. Please note: If the patient's condition requires a significant, separately identifiable E&M service above and beyond the other service provided or beyond the usual preoperative and postoperative care associated with the procedure that was performed, modifier -25 is appended to the appropriate level of E&M service. Although the service may be prompted by the symptom or condition for which the procedure and/or service that was provided; different diagnoses are not required for reporting of the E&M services provided on the same date. Essentially, modifiers were designed to give Medicare and commercial payers additional information needed to process a claim. They provide the means by which a physician or facility can identify a service provided that has been altered by some special circumstance(s), but for which the basic code description itself has not changed. Therefore, keeping this in mind, the usage of these modifiers must be substantiated in the patient's medical record.

21 Emergency Department E&M with a Minor Procedure Code?
Case # 1 – Patient presents to the emergency department (ED) with a foreign body in the eye. The physician exams the eye and the foreign body is removed. Case # 2 – Patient presents to the ED complaining of eye pain. The physician does a complete evaluation of the eye to include fluorescein dye and Wood’s lamp to check the eye for a corneal abrasion or foreign body. Upon evaluation of the patient, the physician determines that the patient has a foreign body in the eye and proceeds to remove it. Case #1 – In this example, a visit E&M should not be coded as the exam of the eye was related to the removal of the foreign body, and no other identifiable problems or issues were addressed at this visit. Case # 2 – In this example, it is appropriate to code for the emergency departments E&M code with a procedure code for the foreign body removal as well. Modifier 25 would be appended to the E&M code. The provider performed a complete eye exam to help determine what the cause of the eye pain was. The fluorescein dye and Wood’s lamp are included with the E&M and are not separately reported (see CPT Assistant, May 2008, page 9-11).

22 Emergency Department E&M with a Minor Procedure Code?
Case # 3 – A 67-year-old female presents to the ED after falling off a three-step ladder. Upon evaluation of the patient and review of radiographs, the emergency department physician determines that the patient sustained a nondisplaced fracture of the distal left ulna. An injection of 60 mg of Toradol IM was administered for pain. Due to the swelling, a plaster molded splint was applied for immobilization and protection of the fracture. The patient is referred to the orthopedic clinic for follow-up treatment in 2 days. Case # 3 - Appropriate level ED E&M code with modifier 25 should be used. The provider performed an appropriate evaluation and had to order and review the x-rays to make a determination of the extent of the patient’s injury. The provider should also report the splint application with a casting/splinting procedure code LT Application of short arm splint (forearm to hand); static (this has a 000 day global time frame) Therapeutic, prophylactic or diagnostic injection (specify material injected); subcutaneous or intramuscular, HCPCS code J1885 Injection, ketorolac tromethamine, per 15 mg

23 Emergency Department E&M with a Minor Procedure Code?
Case # 4 – A 70-year-old female presents to the ED following a left ankle injury when her foot became twisted in her dog’s run chain. The ED physician evaluates the patient and upon review of the radiographs, questions whether there is an ankle fracture, and orders further radiologic views that substantiated the diagnosis of a sprained ankle ligament. A short-leg plaster posterior molded splint is applied due to the degree of swelling to protect the injury. The patient is provided with appropriately-fitting aluminum crutches, and instructed by ED in crutch-walking technique. The patient is to scheduled with an outpatient Orthopedic provider in 2 days to f/u and provide definitive fracture treatment care. Reference from CPT Assistant, 2002, page 13 – Modified for this presentation to reflect “physician” coding in place of the “facility” coding referenced in the article. Case # 4 – The ED provider would code the following for his/her services based on the documentation above: Appropriate level ED E&M code with modifier 25 appended. 29515-LT Application of short leg splint (calf to foot). HCPCS cast/splint supply codes would not be used for the initial treatment care: MHS coding guidelines Cast or Splint Application All casts and splints applied will be coded when not bundled with another procedure on the ordering privileged provider’s SADR, with the technician listed as a secondary provider. When applying other than the initial cast or splint, also use the casting and splint codes Q4001–Q4051. A CPT code for crutch training would not supported based on this documentation. The code for crutch training is a timed code (15 minutes of service) and the time is not specified, and a proper note is not documented to support this code.

24 What do you think the provider should code for this?
Brain Teaser Case # 1 – Emergency department visit for an otherwise healthy patient whose chief complaint is a red, swollen cystic lesion on his/her back. Problem-focused history is documented. The provider performs a limited exam of the lesion and determines this to be a furuncle. After informed consent is signed and the patient is prepped with a sterile field, the provider proceeds to open the lesion with a surgical blade, allowing the contents to drain. Gauze strip packing is inserted to assist with drainage. A loose gauze dressing is applied over the wound. Patient tolerated the procedure well and was given a topical ointment to apply BID. The patient was told to follow up in the F/P clinic in 2 days for a recheck of the wound. What do you think the provider should code for this? Case # 1 - Per Coding Companion for Emergency Medicine, AMA, 2005 10061 – Incision and drainage of abscess (carbuncle, cyst, furuncle, etc…) , complicated or multiple. The complicated code is used when an I&D is performed and packing is performed to assist with drainage and healing. The provider did not perform any additional evaluation and management, unrelated to the abscess therefore a separate E&M would not be appropriate in this example. The CPT code includes the surgical tray and typical supplies therefore you would not need to append a HCPCS code for these products. 680.2 ICD – Carbuncle and furuncle of truck is added to support the procedure code.

25 Brain Teaser Case # 2 – During the course of treatment, Patient A gets her left long-arm fiberglass cast wet prior to her next scheduled follow-up appointment. She arrives at the outpatient orthopedic clinic, where her left long-arm cast is removed, skin evaluated, and another long-arm, fiberglass cast is reapplied. Coded with E&M based on documentation, and for the reapplication of a new cast. Is this correct coding? Reference from CPT Assistant, 2002, page 13 – Modified for this presentation to reflect “physician” coding in place of the “facility” coding referenced in the article. Answer = NO – the provider is missing a few codes and a modifier for this example. Hospital Orthopaedic Outpatient Clinic Setting Appropriate level outpatient office E&M code. The provider took the old cast off and did an evaluation of the skin. With proper documentation you could add an additional E&M for the work not related to the fracture care. (Append 25 to the E&M code) 29705-LT Removal or bivalving; full arm or full leg cast 29065-LT Application, cast; shoulder to hand (long arm) In this example you would be able to code for the HCPCS supply code for the replacement casting material.

26 References 2010 AMA CPT Manual, Professional Edition CPT Assistant: Preventive Medicine Services (May 2002); Modifier -25 – Making the Right Decisions, Part I (November 2004), Part II (December 2004. National Correct Coding Initiative (NCCI) Policy Manual for Medicare Services; Version 13.3, pages I 10-I 13. CMS Medicare Learning Network, MLN Matters # MM5025. Unified Biostatistical Utility (UBU) : Submit coding questions on the PASBA Website: https://pasba3.amedd.army.mil/login/login.fcc


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