Coding Strategy

Understand ‘significant’ and ‘separate’ to earn a gold star.

Knowing when to report modifiers and choosing the best one for each situation can be an easy trip-up for coders. If you find yourself especially befuddled by modifier 25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service), keep reading for real-world tips that will help you code confidently every time.

Starting point: Remember you can only consider reporting modifier 25 when coding an E/M service. If the procedures you’re reporting don’t fall under E/M services, check whether the encounter qualifies for modifier 59 (Distinct procedural service) instead.

1. Verify That Service Is Significant

As CPT’s Appendix A explains, a significant and separately identifiable service “is defined or substantiated by documentation that satisfies the relevant criteria for the respective E/M service to be reported.” Ask yourself two questions when deciding if your case meets the criteria:

• Could the complaint or problem stand alone as a billable service? A single trigger point injection (20552, Injection[s]; single or multiple trigger point[s], 1 or 2 muscle[s]), for example, qualifies as a stand-alone service you might see in conjunction with an E/M visit.
• Do you have a different diagnosis for the portion of the visit unrelated to the initial service? For example, the patient might be in the office for a planned knee injection, but also complains of shoulder pain during the visit.

Reporting an E/M code with modifier 25 would be appropriate for the services performed and documented concerning the shoulder.

If you can answer “yes” to either question, you’re one step closer to reporting modifier 25.

Example: “My physicians complete a lot of lumbar and cervical injections that have a 0-day global period,” says Mary Baierl, RHIT, CPC, CCA, CMT, a coder with BayCare Clinic, Pain Management and Rehabilitation Medicine in Green Bay, Wis. “When they evaluate the patient in the office, offer an injection, and have time to do the injection that day, we code the injection and include office visit E/M code with modifier 25 as a separately identifiable service.”

2. Check for Additional Work

If the diagnosis remains the same, Quita Edwards, CCS-P, CPC, COSC, CPC-I, owner of CASE Contracting Services in Fort Valley, Ga., says you have a third question to ask: Did your orthopedist perform extra work that went above and beyond the typical pre- or postoperative work associated with the procedure code? Another affirmative answer points you to modifier 25.

Example: A patient comes to your office for a scheduled joint injection. She has received injections to treat knee pain due to osteoarthritis but they don’t provide long-term relief. During the appointment your physician says she needs to begin thinking about surgical intervention. He spends between 30 and 40 minutes discussing the risks and benefits of surgery so the patient can make an informed decision.

Even though the diagnosis you report for the injection and the E/M service will be the same, you can separately report the two services in this case. “The physician spent enough time discussing the surgery to count as significant and separately identifiable from the injection,” Edwards explains. “You can bill an E/M code with modifier 25 based on the amount of time he spent, even though he didn’t evaluate the patient.”

3. Look for Pre-Planning

Modifier 25 is meant for those “oh, by the way” type situations, not procedures that are tied to previous services. Consider these scenarios and whether you think they merit modifier 25, then watch the Medical Coding News for our experts’ recommendations.

Scenario 1: Your orthopedist sees Mrs. Jones in the office and gives her a prescription for pain medication to help her wrist pain. He says that if this doesn’t help, he’ll give her a wrist injection when she returns. Mrs. Jones returns to the office two weeks later for the injection. Your physician completes another evaluation prior to administering the injection.

Scenario 2: Your physician treats Mrs. Adams for a minor shoulder injury. She returns a few days later because her arm was snatched during activity and she’s experiencing significant pain. The physician completes a full evaluation before prescribing treatment.

Scenario 3: Your surgeon completes total hip arthroplasty on Mr. Brown. Six weeks after the surgery, Mr. Brown returns to your office and sees a different physician because of an ankle sprain.

@ Orthopedic Coding Alert

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Sample ICD-9 codes to support medical necessity for trigger point injections.

Counting the right items, knowing insurer-allowed diagnoses, and documenting affected muscles will get your trigger point injection (TPI) claims paid while protecting you from paybacks.

Further, knowing each insurers’ covered diagnoses for TPIs is vital to healthy coding.

√ Do Count Muscles Injected

Coders should report 20552 (Injection[s]; single or multiple trigger point[s], 1 or 2 muscles) when the internist injects one or two muscles, confirms Marvel J. Hammer, RN, CPC, CCS-P, PCS, ACS-PM, CHCO, of MJH Consulting in Denver.

When the internist injects three or more muscles, opt for 20553 (… single or multiple trigger point[s], 3 or more muscle[s]).

Remember, “coding is based on the number of muscles injected, not the number of trigger points in those muscles OR the number of injections into those muscles,” Hammer relays.

√  Do Check for Acceptable ICD-9s

Patients suffering from muscle pain receive TPIs for relief; however, the types of pain that justify TPIs are entirely up to the payer. Diagnoses that prove medical necessity for TPIs vary greatly. Some insurers cover only 729.1 (Myalgia and myositis, unspecified), while others have expanded the list of ICD-9 codes that support medical necessity for TPIs.

Best bet: Check with your payer for its specific list of acceptable ICD-9s on TPIs.

In addition to 729.1, 728.85 (Spasm of muscle) and 729.4 (Fasciitis, unspecified) are also common diagnoses for TPI, Hammer explains.

Here is a sampling of other acceptable ICD-9s for TPIs from the local coverage determination [LCD] for First Coast Service Options, a Florida Medicare carrier:

• 726.30-726.39 — Enthesopathy of elbow region

• 726.70-726.79 — Enthesopathy of ankle and tarsus

• 727.00-727.09 — Synovitis and tenosynovitis

× Don’t Skimp on TPI Documentation

When reporting TPI encounters, experts recommend including a list of the muscles the internist injects. “Since the coding is based on number of muscles, the provider should absolutely document the specific muscles injected,” Hammer explains.

“Otherwise, the most that you could code is 20552, as the documentation could not support that three or more separate muscles were injected,” she says.

Providers should also include documentation of the drug(s) that were injected to clarify that the procedure was an injection and not “dry-needling,” which some payers do not cover, says Hammer.

You should check with your carrier if you are unsure of the specific substances your payer will accept on TPIs.

Use these J codes for drugs the internist might inject during TPI:

• J1020 (Injection, methylprednisolone acetate, 20 mg) for Depo-Medrol

• J1030 (Injection, methylprednisolone acetate, 40 mg) for DepoMedalone40, Depo-Medrol, or Sano-Drol

• J1040 (Injection, methylprednisolone acetate, 80 mg) for Cortimed, DepMedalone, DepoMedalone80, Depo-Medrol, Duro Cort, Methylcotolone, Pri-Methylate, or Sano-Drol.

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