You may need to append modifier 25, depending on payer policies.

Question: Our physician billed 90634, 90710, and 90606 for vaccines given to a 5-year-old patient. The insurance company denied payment and said they required a modifier. What should we have done differently?

New Hampshire Subscriber

Answer: According to standard CPT coding, vaccine codes do not require modifiers on the associated E/M code. However, you might need to include modifier 25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) if your insurance company requires it — which might be why you received a denial.

Well check: If your physician administered vaccines on the same day as a well visit, code the well visit with the appropriate code such as …

… 99393 (Periodic comprehensive preventive medicine reevaluation and management of an individual including an age and gender appropriate history, examination, counseling/anticipatory guidance/risk factor reduction interventions, and the ordering of laboratory/diagnostic procedures, established patient; late childhood [age 5 through 11 years]). You might need to append modifier 25 if vaccinations are given, depending on the payer’s guidelines.

Sick visit: If the child visits because of another problem and receives immunizations during the visit, report the vaccines with the appropriate office visit code from 99212-99214 (Office or other outpatient visit for the evaluation and management of an established patient …).

Then report the vaccine codes: 90634 (Hepatitis A vaccine, pediatric/adolescent doage-3 dose schedule, for intramuscular use), 90696 (Diphtheria, tetanus toxoids, acellular pertussis vaccine and poliovirus vaccine, inactivated -D-TaP-IPV], when administered to children 4 through 6 years of age, for intramuscular use), and 90710 (Measles, mumps, rubella, and varicella vaccine [MMRV], live, for subcutaneous use).

@ Pediatric Coding Alert

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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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Insurers might want to see a clear explanation as to why the E/M was necessary.

Question: An established patient with a plan of care in place for her gastroesophageal reflux disease (GERD) reports to the gastroenterologist; two weeks ago, the gastroenterologist started her on Nexium (esomeprazole). One of the practice’s nonphysician practitioners (NPPs) evaluates the patient, taking blood pressure and other vitals. She also asks the patient if she has experienced any nausea, diarrhea, vomiting, or any other side effects since she started Nexium. The patient reports that she’s “thrown up three or four times” since starting the medication, but reports no other side effects. The patient’s record indicates that the gastroenterologist scheduled this visit specifically to check how the patient’s adjustment was going. What can I report for this encounter?

Answer: It will depend on the encounter specifics, but this sounds like a 99211 (Office or other outpatient visit for the evaluation and management of an established patient, that may not require the presence of a physician. Usually, the presenting problem[s] are minimal. Typically, 5 minutes are spent performing or supervising these services …) service.

No matter what E/M code you choose, append the following diagnosis codes:

• 530.81 (Other specified disorders of esophagus; esophageal reflux) to represent the patient’s GERD
• 787.03 (Vomiting alone) to represent the patient’s vomiting

Explanation: The gastroenterologist will often order a patient to report soon after starting a new medication regimen; these scheduled visits are typically 99211 encounters, though they can theoretically be higher-level if complications arise.

For medication checkup encounters, insurers might want to see a clear explanation as to why the E/M was necessary. Cut off any payer queries by including the following documentation on medication checkup E/Ms:

• a record of patient’s blood pressure, if relevant, and other vital signs
• a note indicating the clinical reason for checking blood pressure or other vital signs
• a list of the patient’s current medications (include level of patient compliance, if possible)
• proof that the gastroenterologist evaluated the clinical information the NPP obtained and made a  management recommendation for the patient.

FREE EM Coding WEBINAR: Find out the medical documentation guidelines your practice is probably missing for HPI.

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Don’t forget to include the code for the arthrocentesis.

Question: A new patient sees the orthopedist because of shoulder problems. The physician schedules an MRI and the patient returns the following week to discuss the findings. The physician had already reviewed the films and goes over them in depth with the patient. He also administered a shoulder joint injection to help relieve the patient’s pain.

What diagnosis should we report with the E/M service to reflect the amount of time spent reviewing films and counseling the patient and to distinguish it from the injection?

West Virginia Subscriber

Answer: Select a diagnosis based on your provider’s documentation, such as rotator cuff tear (840.4, Sprains and strains of shoulder and upper arm; rotator cuff [capsule], or 727.61, Rupture of tendon, nontraumatic; complete rupture of rotator cuff). Include that diagnosis with …

… the appropriate E/M code for your physician’s service (99211-99215, Office or other outpatient visit for the evaluation and management of an established patient …). Append modifier 25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) to the E/M code.

Also report 20610 (Arthrocentesis, aspiration and/or injection; major joint or bursa [e.g., shoulder, hip, knee joint, subacromial bursa]) with 719.41 (Pain in joint; shoulder region) for the shoulder injection.

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Check out these ICD-10 ob-gyn diagnosis coding equivalents.

Question: A patient presented for an initial OB visit. Another clinic confirmed her pregnancy, but she has never received prenatal care. The patient got her usual initial OB service (i.e. lab orders), Pap smear, and chlamydia trachomatis (CT)/neisseria gonorrhoeae (GC) screening. After discussing some concerns with the patient, the ob-gyn ordered another pregnancy test which came out negative. He ordered an ultrasound (US) which showed no intrauterine pregnancy. The ob-gyn noted bilateral polycystic ovaries, however. In short, the office completed the initial OB visit prior to knowledge of a negative pregnancy test (given the confirmation documentation of a positive pregnancy test). I’m not sure whether to bill it as an initial or an office visit. What code should I use for the first diagnosis?

California Subscriber

Answer: Your clue is to code what you know at the end of the visit. Since the patient was not pregnant, you should report …

… an outpatient E/M visit (99201-99205, Office or other outpatient visit for the evaluation and management of a new patient …; 99212-99215, Office or other outpatient visit for the evaluation and management of an established patient …). As it turned out, you were not providing global OB care nor were you supervising a pregnancy after all.

Your final diagnosis should be 256.4 (Polycystic ovaries) with V72.41 (Pregnancy examination or test, negative result). According to the CPT Assistant, you would code the ultrasound as an OB ultrasound (76805-76815). Therefore, you should link the ultrasound to V72.41. Here’s what the guideline states:

“For a patient with an established diagnosis of pregnancy (determined by any means), with signs and symptoms that could be pregnancy related and necessitating an ultrasound evaluation of the pelvis, the obstetrical ultrasound code(s) 76805-76815 should be reported, even if the outcome of the procedure is that the patient is now not pregnant or has an ultrasonic diagnosis that might be construed as being independent of the pregnancy (e.g., acute appendicitis, torsed ovary, necrotic fibroid).”

ICD-10: Your new ICD-10 system will list 256.4 as E28.2 (Polycystic ovarian syndrome). V72.41 will be replaced by Z32.02 (Encounter for pregnancy test, result negative).

@ Ob-gyn Coding Alert

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