Modifier 25 is a particularly meaningful coding tool for physicians who bill for evaluation and management (E/M) services. CPT guidelines define the 25 modifier as “Modifier 25 is defined as…
Q: Can you clarify when an evaluation and management (E/M) code can be billed with a physical on the same day? A: This is always a difficult coding scenario to…
If your dermatologist is treating vitiligo or dychromia patients with phototherapy, read your physician’s documentation carefully to determine what type of light, wavelength, and materials he used. These two frequently asked questions will help you combat both E/M and multi equipment correct coding initiative (CCI) situations.
Evaluate These Phototherapy + E/M Tips
If you’re charging for an office visit on the same day as phototherapy, your reimbursement may depend on whether your physician’s documentation warrants a different diagnosis code. Payers may reimburse at times if the doctor sees the patient for a different problem, thus with a different diagnosis code, experts say.
Example: If your physician performs 99212 (Office or other outpatient visit for the evaluation and management of an established patient … Physicians typically spend 10 minutes face-to-face with the patient and/or family) with phototherapy, you will bill it with modifier 25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) on the E/M service. You can only consider reporting modifier 25 when coding an E/M service, Janet Palazzo, CPC, a coder in Cherry Hill, N.J., says. Remember your E/M documentation has to show medical necessity for the additional work.
If you reported the nurse visit code 99211 (Office or other outpatient visit for the evaluation and management of an established patient, that may not require the presence of a physician …), your payer would likely consider it bundled into the light treatment.
Ask 2 Questions to Choose Best Light Therapy Code
For patients with vitiligo (709.01), your dermatologist may use narrow band UVB phototherapy.
The dermatologist administers phototherapy two to three times per week for several months until the patient achieves repigmentation of the skin. For this procedure, you need to pinpoint what types the...
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...
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...
March 21, 2007
Dear JCAAI Member:
We recently surveyed JCAAI members regarding reimbursement for an E&M service on the same day as a skin test or on the same day as an injection (95115 – 95117). Well over 80% are paid for an E&M service on the same day as a skin test. Far fewer are paid for an E&M service on the same day as an injection. In particular, the majority of allergists reported that they were not paid for an injection on the same day they billed a minimal office visit (99211).
Under Medicare policy, neither the injections codes nor the skin testing codes have global periods. Codes that have global periods (typically procedure codes) usually cannot be billed with an office visit because the E & M service is considered bundled into the procedure. Codes that do not have global periods do not include any bundling of E & M services; thus, coding policy generally permits them to be billed on the same day as an E & M without the use of modifier-25. However, as our survey results indicate, not all payers are aware of or are following this policy. This may be because, until January 1, 2006, the injection codes were classified as global period codes (which meant that they could not be billed with an E & M service without the use of modifier-25). JCAAI was successful in getting Medicare to change this so that you are allowed to bill an E & M service (including 99211) with allergy injection codes without meeting the requirements for modifier-25. The primary reason for this change was to allow a physician to bill 99211 when dealing with clinical issues surrounding allergy injection administration (e.g., directing a nurse giving injections as to what the nurse should do if...
Medicare still won’t reimburse audiologist-billed Epley. After two years of battles with CMS over canalith repositioning procedure (CRP) coding, physicians will finally get paid for these specific codes. CPT® 2009 excited ENT coders with new CPT cod...
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,...
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...
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,...
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...
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…
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…
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…
Related articles:Reading 44373’s code descriptor is key to getting your G Tube claim right. Question: The gastroenterologist goes to the hospital to treat a patient that had recently been admitted because his gastrojejunostomy tube had migrated to his stomach. After performing a problem focused interval history and exam, the gastroenterologist decides to perform an EGD to reposition the [...] Related articles:
Heads up: 2 nosebleed codes are not the answer. Question: A patient reports to the ED after sustaining injuries during a soccer match; she was hit in the face with a ball, her nose is bleeding, and her right eye is blackened. The physician is not able to stop the bleeding with ice or pressure, so [...] Related articles: