Title: Modifier 25 – When to Pick Up the Procedure Session: W-5-1100

1. Title: Modifier 25 – When to Pick Up the Procedure Session: W-5-1100

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.

3. Modifier 25 Defined (cont’d) • 6.7.4. 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?

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

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.

6. Modifier 25 andPreventive 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.

7. Modifier 25 andPreventive 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.

8. Modifier 25 andPreventive 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.

9. Modifier 25 andPreventive 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.

10. Modifier 25 andPreventive 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.

11. Modifier 25 andPreventive 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 (99381-99397) and an office or other outpatient service (99201-99215) 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, 99201-99215) as an established patient? 

12. Global Coding and Modifier 25 Section 5.3.2 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.

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.

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 73030 (x-ray study of shoulder), and CPT 20610 (injection, shoulder). Do you agree?

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.

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 CelestoneSoluspan 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.

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.

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.

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 99214. 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. Do you agree? Case # 10 – Can my doctor report an office visit when he performs chiropractic manipulative treatment?

20. Emergency Department E&M with a Minor Procedure Code? Transmittal A-00-40 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.

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.

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.

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.

24. 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?

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 29065 for the reapplication of a new cast. Is this correct coding?

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) : • http://www.tricare.mil/ocfo/bea/ubu/index.cfm • Submit coding questions on the PASBA Website: • https://pasba3.amedd.army.mil/login/login.fcc