Family practice coding & proper modifier 25 use

You should stop omitting modifier 25 because of same day diagnosis.

Recently, someone told me that we do not require different diagnosis codes to use modifier 25 for reporting an Evaluation & management service on the same date as a procedure. However, I have been told many times in the past by certified coders that when I bill more than a procedure that I need to add modifier 25 to the evaluation & management and point the primary diagnosis to the evaluation & management and point a secondary diagnosis to the other procedure. Can you help clear up my doubt?

Answer: Proper modifier 25 use doesn't need a different diagnosis code. As a matter of fact, the presence of different diagnosis codes attached to the E/M and the procedure doesn't support a separately reportable E/M service.Your key to reporting the E/M service lies in whether your doctor carried out and documented work beyond what's considered to be part of the procedure.

How if functions: The information about modifier 25 in the CPT manual distinctly indicates that you don't need to have two different diagnosis codes to use the modifier. As per the CPT manual description of modifier 25, the evaluation & management service may be prompted by the symptom or condition for which the procedure and/or service was provided. Therefore, different diagnoses are not required for reporting of the E/M services on the same date."

Both CPT and Medicare rules will allow the same diagnosis for the evaluation & management service with modifier 25 and the procedure on the same day, and Medicare will pay for both with the same diagnosis, assuming both are reasonable and necessary and otherwise meet Medicare coverage criteria. The catch is that your physician's documentation should establish clearly that the evaluation & management involved work over and above that typically associated with the procedure done at the same encounter and that the encounter's sole intention was not to carry out the procedure. So if you get denials on modifier 25 claims just because you use the same diagnosis code for the Evaluation & management and the procedure, you should appeal, assuming your physician's documentation supports reporting separate services.

Ob-Gyn Coding: Ensure You've Got Well-Documented Adhesions Ob-Gyn Coding: Ensure You've Got Well-Documented Adhesions

In a particular scenario, my ob-gyn carried out an "operative laparoscopy adhesiolysis, abdominal myomectomy." How should you report this?

Well, to put it in other words, your ob-gyn carried out laparoscopic lysis of adhesions, then converted to an open myomectomy. For the laparoscopic lysis of adhesions, you should code 58660. In order to report this code, you should ensure that the type of adhesions your ob-gyn addressed is the kind that payers normally pay. If your ob-gyn doesn't describe the adhesions in the op report thoroughly, trying to report the lysis is a waste of your time and a line item on the claim form.

You should either report 58140 or 58146 for the abdominal myomectomy.

While listing the codes on your claim, list 58140 or 58146 first followed by the lysis code (58660). You do not require a separate procedure modifier since you will not find this code combination bundled in the National Correct Coding Initiative (NCCI).

Heads up: See to it that you include V64.41 as a diagnosis for the open procedure in addition to the diagnosis for the surgery itself.

Remember: If the ob-gyn intended to do a laparoscopic myomectomy and found adhesions but did not remove them laparoscopically, then converted to carry out the abdominal myomectomy, you should bill the myomectomy code (Increased procedural services) with modifier 22 (Increased procedural services) only. Payers will bundle the lysis in this situation.

Family practice coding: Which code for emphysema visit?

Here's a family practice coding scenario: When an established patient with emphysema presents complaining of shortness of breath, which CPT code should you go for? The physician provides inhalation treatment, teaches the patient on using the nebulizer at home, and provides an expanded problem-focused examination and medical decision-making of low complexity.

Well, you'll require more than one CPT code for this encounter. Use 94640 to cover the all-encompassing service the physician provided.

Since the doctor also carried out an office visit, go for 99213 based on your documentation of an expanded problem-focused exam with low-complexity decision-making. You might require to add modifier 25 to 99213 to indicate that the evaluation & management service was significant and separately identifiable from 94640.

Go for 94640 in place of 94664 as the physician's main intent was to treat the obstruction.

A word of caution: If you bill 94664 with 94640 on the same day to Medicare, see to it that you justify that the doctor provided the 94664 service distinctly separate from the treatment. In this instance, add modifier 59 to 94664 to notify the payer that the FP carried out 94664 separate from 94640. The documentation should include details on the medical necessity for separately providing this service.

Here's an instance: The doctor determined that the patient's plan of care should include inhalation therapy or the patient is new to this therapy and doesn't know the administration techniques involved in the procedure. The note should clearly show that the doctor demonstrated the inhaler to the patient separate from the administration for treatment. Or else, the insurer may think you're trying to report one service twice.

Note: even though it's technically not required, it may link separate diagnosis codes to the E/M and the nebulizer treatment. Say for instance, you could link 786.05 to 99213, and link the emphysema code (492.8, Other emphysema) to 94640.