Clearly separate documentation when appending modifiers -25 and -59
August 25th, 2014 - Lisa EramoModifiers. They’re those pesky numbers that coders must append to a code in order to ensure proper reimbursement. What modifier is most appropriate? Does documentation support its use? Could the practice successfully defend its usage during an audit? These are just a few of the questions that coders regularly.
During AAPC’s 22nd annual HEALTHCON conference held earlier this month in Nashville, TN, two healthcare attorneys participating in a legal trends panel discussion cited modifiers as the top compliance concern facing today’s practices. They specifically flagged modifiers -25 and -59 as being particularly challenging.
Katherine Abel, CPC, CPB, CPMA, CPPM, CPC-I, director of curriculum at AAPC, talked about these and other modifiers during a presentation given to a room filled with dozens of physician practice medical coders. Following is some of the advice she provided.
Modifier -25
Modifier -25 denotes a significant, separately identifiable evaluation and management service that a physician or other qualified healthcare professional performs on the same day that he or she performs another procedure or service.
To correctly append modifier -25, coders must know the global period for each CPT code, including the typical pre-, intra-, and post-operative services included with each procedure, as these services are not separately billable, said Abel. Coders can easily search the entire fee schedule for this and other information about specific codes.
When coders append modifier -25 to an E/M code, carriers will pay for both the medically necessary E/M service as well as the procedure. Abel said coders should keep this in mind because the modifier can trigger overpayments if appended improperly. However, the modifier can also increase revenue if used correctly.
She urged coders show providers an example of how small overpayments due to this modifier can add up over time, resulting in thousands of dollars inappropriate payments annually.
For example, when coders report 20610 ($60.90) with 99213-25 ($73.08), they’ll receive a total of $133.98.
“A provider may look at an individual instance of $73.08, but if you annualize it an apply some of the penalties you can get from doing this, it gives [providers] a bigger picture to look at to help them understand what it is their doing and the risk they’re putting themselves at.”
Abel urged coders to keep in mind that E/M services performed on the same date of service as a minor surgical procedure (i.e., a procedure with a global period of 000 or 010 days) are generally included in the payment for that procedure. She cited this example of improper use:
A patient complains of left knee pain. A physician evaluates the knee and determines that the patient would benefit from arthrocentesis. The physician gives the patient an injection and schedules a follow-up visit for one month.
In this scenario, the evaluation and management is not separately billable in addition to the injection, said Abel.
However, she noted that payer policies pertaining to modifier -25 may differ. Each payer may have different criteria for usage as well as items that don’t meet those criteria. For example, BCBS of TN specifies that coders cannot append modifier -25 when a physician performs a minor procedure. BCBS of Alabama states that the decision to perform a minor procedure is a pre-requisite of appending modifier -25. Clearly, these two policies contradict one another.
Aside from checking payer policies, Abel also urged coders to literally separate the documentation of the E/M service from the procedure in order to better understand whether the E/M service could be billed separately. She suggested using a highlighter to identify documentation pertaining to one of the two services. Then ask whether there is enough documentation remaining to support reporting the other service.
“When you separate it out like this, it is very clearly seen,” she said. When appealing denials for modifier -25, coders can then attached this note with highlighted documentation to bolster support for their appeal letter.
Another suggestion was to simply ask physicians what pre- and post-operative services they normally include with certain procedures. This makes it easier to identify instances in which physicians go above and beyond what might normally be considered part of the procedure.
She referred coders to the National Correct Coding Initiative (NCCI) Policy Manual for Medicare Services (revised January 1, 2014) for more information and encouraged them to read through the general chapter. She also stated that coders should review the NCCI edits to determine whether modifier -25 may even be applicable. Download the physician—not hospital—version of these edits.
Modifier 59
Modifier -59 denotes a distinct procedural service, including a different surgical session, different procedure or surgery, different site or organ system, separate excision or incision, or separate lesion or injury.
In addition to reviewing NCCI edits and policy manual, Abel urged coders to review specific payer policies as well as Medically Unlikely Edits. Then ask these questions:
· Was the procedure performed in a separate setting, different time, or different encounter?
· Is there sufficient documentation to support the separateness and distinction of the two procedures?
· Was the procedure truly separate and/or is it unusual to perform these procedures at the same session?
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