Coding Strategy

This modifier is key to E&M and counseling codes cohabiting on your claim.

Question: Can I report alcohol cessation counseling codes along with E/M codes, or do I have to choose one or the other?

Idaho Subscriber

Answer: You can, and in most cases will, report counseling codes along with E/M services. The behavior change intervention codes are intended to be reported in addition to an E/M service when the provider furnishes them. Most counseling sessions occur after the provider performs some sort of E/M. Consider this case study:

A new patient presents to the gastroenterologist reporting intense heartburn and “vomiting bile” for about a week. The patient’s skin is a splotchy yellow, and he reports experiencing generalized fatigue “for as long as I can remember.” Due to the smell of alcohol and the patient’s symptoms, the physician asks the patient if he has been drinking. The patient says “Yes,” so the physician decides to conduct the CAGE test to gauge alcohol abuse

Based on the test results, the physician determines that the patient is at least moderately dependent on alcohol; she performs extensive counseling and recommends the patient start attending Alcoholics Anonymous or some other community support group for alcohol-addicted individuals.The physician then finishes her patient exam.

She also recommends that the patient schedule a follow-up visit for a cirrhosis screening. The alcohol counseling lasted 18 minutes, and notes indicate the physician also performed a level-two E/M.

In this instance, the gastroenterologist performs both an E/M service and alcohol counseling. On the claim, you would report the following:

• 99202 (Office or other outpatient visit for the evaluation and management of a new patient, which requires these three key components: an expanded problem-focused history; an expanded problem-focused examination; and straightforward medical decisionmaking…) for the E/M;
• modifier 25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) appended to 99202 to show that the E/M was a separate service from the counseling;
• 787.04 (Bilious emesis) appended to 99202 to represent the vomiting;
• 787.1 (Heartburn) appended to 99202 to represent the heartburn;
• 782.4 (Jaundice, unspecified, not of newborn) appended to 99202 to represent the skin condition;
• 780.79 (Other malaise and fatigue) appended to 99202 to represent the patient’s fatigue;
• 99408 (Alcohol and/or substance [other than tobacco] abuse structured screening [e.g., AUDIT, DAST], and brief intervention [SBI] services; 15 to 30 minutes) for the counseling service; and
• 305.00 (Alcohol abuse; unspecified) appended to 99408 to represent the patient’s alcohol dependence.

@ Gastroenterology Coding Alert. Editor: Chris Boucher, CPC

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Here’s why you should append modifier 25.

Question: A 47-year-old male reports to the ED complaining of a painful, swollen, and reddening right thumb. The physician performs an expanded problem focused history and examination, which uncovers two splinters. The ED physician cannot grasp the splinters with tweezers, so she uses a scalpel to make two small incisions above the splinters. The physician then uses tweezers to remove both pieces of wood. The notes do not indicate evidence of infection at the extraction site; medical decision making is moderate. Can I code this as a foreign body removal (FBR)?

Kentucky Subscriber

Answer: Since the physician made an incision before removing the splinters, this is an FBR. On the claim, report the following:

• 10120 (Incision and removal of foreign body, subcutaneous tissues; simple) for the FBR
• 99282 (Emergency department visit for the evaluation and management of a patient, which requires these 3 key components: an expanded problem focused history; an expanded problem focused examination; and medical decision making of low complexity …) for the E/M
• modifier 25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) appended to 99282 to show that the E/M and FBR were separate services
• 915.6 (Superficial injury of finger[s]; superficial foreign body [splinter] without major open wound and without mention of infection) appended to 10120 and 99282 to represent the patient’s injury.

Explanation: The incision, or lack of it, drives code choice in this scenario. If the physician had removed the splinters without making an incision, you would have rolled the removal work into the E/M service and left 10120 off the claim.

@ ED Coding Alert

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Upcoming policy change will slash your payments by half.

Big changes are on the horizon if you participate with insurance provider Horizon Blue Cross Blue Shield (BCBS) of New Jersey.

In a recent memo, BCBS states that effective May 17, 2010, they will cut reimbursement by half on many modifiers, regardless of the circumstances surrounding their use. Your practice might stand to lose thousands of dollars. Take a look at the policy details.

Beware a New Reimbursement Trend

The February 2010 memo offers a list of modifiers that BCBS states “will be considered nonstandard — that either the full service was not performed or that the service in question was performed in conjunction with another service or procedure.”

If the policy proceeds as planned, the move will create logistical migraines for those submitting to Horizon BCBS in NJ, experts warn. Many industry watchers hope that this policy will not set a deeply troubling precedent across the country.

Expect the Worst for Modifiers 25, 59

Of the modifiers being cut, the effects on modifier 25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) and modifier 59 (Distinct procedural service) may have the greatest impact for your practice.

Important: The memo states that evaluation and management (E/M) services that are appropriately appended with modifier 25 will pay “at 50 percent of the applicable Horizon BCBSNJ fee schedule amount. This recognizes that the service in question was rendered in conjunction with a separately identifiable E&M service performed on the same day by the same practitioner.”

“In general, it’s becoming tougher every day to get payers to pay with a 25 modifier,” says Karla Westerfield, COPM, business manager at Southeast Wyoming Ear, Nose and Throat Clinic in Cheyenne.

Modifier 59 will also receive the same drastic 50 percent reduction. “I feel that even though the 25 modifier is going to hurt practices, it will not be as much of a ‘hurt’ factor as the situation with the 59 modifier,” says Brian Fornutaro, a billing professional with Medi-corp in Cranford, NJ.

Reasoning: Horizon’s memo states that it is following CMS Correct Coding Institute (CCI) guidelines for appropriate use of the modifiers. CCI edits do not allow a reduction on modifier 25, however. They do allow a modifier 59 reduction as part of the multiple procedure reduction rules.

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Don’t separately report a cursory H&P from the sleep code.

Question: If a nurse practitioner (NP) performed an H&P (history and physical exam) or a subsequent visit with a patient prior to a sleep study, can you bill the H&P with modifier 25 and the sleep study code? Is the H&P included in the sleep study?

Florida Subscriber

Answer:

The visit has to be an evaluation for something other than scheduling a sleep study. It is fairly unusual that the pulmonologist would see the patient in the day time and conduct a sleep study on the same night. Because the sleep study would usually occur on a different day (and perhaps for a different reason), you should code 99201-99205 or 00212-99215 (Office or other outpatient visit, for the evaluation and management of an established patient) one day and 95811 (Polysomnography; sleep staging with 4 or more additional parameters of sleep, with initiation of continuous positive airway pressure therapy or bilevel ventilation, attended by a technologist) on a different day. Remember a NP should report the patient evaluation in her own name.

Note: A cursory H&P (immediately prior to initiation of the study) is not separately reported from the sleep code.

Another option: If the NP only saw the patient, then the NP would code 99201-99215 and the practice would receive 85% of the payment.  The pulmonologist would code for the sleep study separately.

@ Pulmonology Coding Alert

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Attach your procedure notes and the OIG’s report to pack extra punch.

Even if you follow all of CMS’s rules in reporting modifier 25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service), your Medicare payer may sometimes still choose to deny your claim.

If you feel you deserve the pay for the EM service you performed, you should appeal the denial. Alice Kater, CPC, PCS, coder with Urology Associates of South Bend in Indiana, offers the following sample appeal letter (below) as an example of how she has challenged her payer to collect rightful reimbursement.

What you should know: To improve her odds of success, Kater submits her physician’s documentation with the appeal letter, as well as a copy of a 2005 letter from Mark B. McClellan, MD, PhD, former HHS administrator, to Inspector General Daniel R. Levinson that was a response to the 2005 OIG report “Use of Modifier 25.”

In addition, Kater includes the first three pages of the OIG report, which outlines the appropriate way to report modifier 25. You can download McClellan’s letter, as well as the OIG report, at http://oig.hhs.gov/oei/reports/oei-07-03-00470.pdf.

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