Hot Coding Topics / modifier 25

AK Removals: Earn $120 by Following 17000-17111 with 99201

Stick to these 3 tips for your E/M and lesion removal procedures.

You can report both the E/M and lesion removal if the E/M service was a significant and separately identifiable service for an E/M service with actinic keratoses (AK) removal procedure.

Always verify with your carrier before appending 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.

You can only consider reporting modifier 25 when coding an E/M service, says Janet Palazzo, CPC, coder for a practice in Cherry Hill, N.J. If the procedures you are reporting don’t fall under E/M services, it is possible the encounter qualifies for another modifier instead.

Have a look at the following three tips to help you report these services accurately so your practice won’t miss out on about $41 for 99201 and $80 for 17000 or more, according to national averages indicated in Medicare’s 2011 Physician Fee Schedule.

1. Know When You Should Charge an E/M

Each insurer has its own guidelines for office visits (99201- 99215, Office or other outpatient visit …) and lesion removals (17000-17111, Destruction, Benign or Premalignant Lesions). So, knowing whether to appeal an E/M denial is difficult unless you know that the service deserves payment.

You should report the office visit (99201-99215) in addition to the procedure when the dermatologist performs a significant, separately identifiable E/M service from the AK removal, especially if the patient is new to your practice.

Along with the appropriate E/M code, report any diagnoses that come with that examination, which may include more than just the AK.

For example, if a patient comes in for an initial AK visit, you should charge an E/M service, since the physician has to examine the area and discuss...

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March 21, 2011
Coding Challenge / Hot Coding Topics / modifier 25

Is 99211 + 95115 OK?

Question: If a nurse has to check vitals to make sure an allergy injection is the correct quantity or if she has to educate the patient about the administration or side effects of the injections, we’ve been billing 99211 with 95115 or 95117. There is...

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December 6, 2010
Coding Challenge / modifier 25 / modifier 50 / modifier 51 / modifier 57 / modifier 59

No Correct Coding Initiative Bundle? Find Modifier Details in MPFS.

Question: Sometimes I cannot find my two-code pair in the CCI edits. How do I know which code would be considered a column 1 code and which would be considered a column 2 code, so that I could put my modifier on the correct code?

Answer: If the codes are not listed, the codes are not bundled per the Correct Coding Initiative (CCI). You would not need a CCI modifier, such as 25 (Significant, separately identifiable evaluation and management service by the same physician on  the same day of the procedure or other service), 57 (Decision for surgery), or 59 (Distinct procedural service), to override the edit when appropriate.

A private payer could have a black box edit. You would need to check with a rep for a recommendation.

Watch out: Just because a code does not have a bundle in CCI does not mean a modifier is out of the picture. While you won’t need a CCI modifier to override the edit, you might need apayment modifier.

You can find Medicare’s other allowed modifiers for any given CPT code in the Medicare Physician Fee Schedule (MPFS). Columns Y-AC indicate if modifier 51 (Multiple procedure), 50 (Bilateral procedure), etc. apply.

To determine which code receives modifier 51, you need to know the code’s relative value units, which are also listed in the MPFS. Private payers may not adjust claim items in descending order as Medicare’s Outpatient Code Editor software does. If you append modifier 51 to a higher valued item, the private payer may apply the adjustment based on your coding, costing you payment. You should instead list the items in descending relative value order from highest to lowest. Append modifier 51 to the lower priced procedure as necessary. The insurer will then apply the typical 50 percent,...

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November 23, 2010
Coding Challenge / E/M / modifier 25 / modifier 26 / radiology

Use 3 CPT, Modifier, and ICD-9 Code Pairs to Ace This X-Ray Claim

Decipher why you should include a seconding diagnosis.

Question: A 38-year-old patient presents to the emergency room with complaints of wheezing, coughing, and trouble catching her breath. After the nonphysician practitioner (NPP) performs a problem-focused history, the physician performs a detailed history and exam and discovers focal ronchi. The physician orders a two-view chest x-ray to check for upper respiratory infection (URI) The chest x-ray results reveal acute URI, and the ronchi clears up upon reevaluation. The patient is treated with antibiotics. How should I code this scenario?

Answer:You’ll submit two of each for this claim: CPT codes, modifiers,and ICD-9 codes. On the claim, report the following:

  • 71020 (Radiologic examination, chest, 2 views, frontal and lateral) for the x-ray
  • Modifier 26 (Professional component) appended 71020 to show that you are coding for the physician’s services only
  • 99284 (Emergency department visit for the evaluation and management of a patient, which requires these 3 key components: A detailed history; A detailed examination;and Medical decision making of moderate 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 99284 show that the E/M and the x-rays were separate services
  • 465.9 (Acute upper respiratory infections of multiple or unspecified sites; unspecified site) appended to 71020 and 99284 to represent the patient’s URI
  • 786.7 (Symptoms involving respiratory system and other chest symptoms; abnormal chest sounds) appended to 71020 and 99284 to represent the patient’s focal ronchi.

Secondary Dx decoded: Even though the focal ronchi cleared up on reexamination, you should still include 786.7 on the claim. It will help paint a more lucid portrait of the patient’s condition, and can only strengthen your medical necessity case for the chest-x-ray.

@ Part B Insider. Editor:...

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May 24, 2010
Coding Challenge / E/M / modifier 25

Ensure Counseling Claims With Pointed Questions

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,...

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May 9, 2010
Hot Coding Topics / modifier 25

3 Situations Boost Your Migraine Treatment Smarts

Acute episodes, check-ups are both routine for these patients.

When migraine headache coding comes up, ICD-9 codes typically dominate the conversation.

But what about the procedure codes those complicated migraine diagnoses are attached to? There are several common situations in...

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May 2, 2010
E/M / Hot Coding Topics / modifier 25

Follow 3 Steps on the Path to Paid Cerumen Removal

Medicare won’t pay 69210 alone, so here’s how to unlock payment.

Impacted cerumen removal is a fairly straightforward procedure, but billing for the procedure is not always so simple.

The problem: Most payers, including Medicare,consider 69210 (Removal impacted cerumen [separate...

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April 15, 2010
Coder's Cranium / CPT / modifier 25

Face Off Against Common Sports Physical Coding Challenges

Hint: Gathering upfront pay and watching E/Ms make a difference.

Children need physicals to participate in their favorite sports year round, but the demand can grow with warm weather approaching. Ideally, the need for sports physicals should provide the opportunity...

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April 14, 2010
Coding Challenge / modifier 25

Look for Incision Evidence in Foreign Body Removal (FBR) Scenarios

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...

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March 28, 2010
CMS / E/M / Medicare / modifier 25 / Oig / Toolkit

Use This Sample Appeal Letter As Ammo in Your Fight Against Modifier 25 Denials

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…

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March 12, 2010
Coder's Cranium / modifier 25 / modifier 76

Breathe New Life Into Your Asthma Coding Claims

Focus on form and drug to pinpoint the correct asthma supply code.

Are you clear on how to report asthma procedures and inhalers? Follow this advice, and you’ll breathe easy when it comes to asthma related claims.

Propellant-Driven Inhaler Falls…

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March 10, 2010
Coding Challenge / E/M / modifier 25 / mumps

Ensure Multi-Vaccine Payment With This Coding Advice

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…

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March 9, 2010
Coding Challenge / E/M / modifier 25

E/M Coding: Use Current Diagnosis to Support E/M Visit

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…

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March 4, 2010