Just because auditors are targeting modifier 25 doesn't mean you should cut out your use of this tool. CMS recently clarified how you should be using modifier 25. See if these common ob-gyn scenarios do or do not merit its use.
Recent reports of the Office of Inspector General (OIG) targeting claims containing modifier 25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) have made ob-gyn practices concerned.
Bottom line: "Every coder should always be concerned and reverent when using modifier 25," says John F. Bishop, PA-C, CPC, president of Bishop & Associates Inc. in Tampa, Fla. "The OIG has really cracked down on this modifier and collected huge sums of money for inappropriate coding."
Best bet: You should only use modifier 25 when your ob-gyn provides a significant and separately identifiable E/M service on the same day as a procedure with a global period.
You can read the CMS clarification (implementation date Aug. 20) at www.cms.hhs.gov/transmittals/downloads/R954CP.pdf.
Scenario 1: Study This Same-Day Biopsy Example
An ob-gyn sees a patient for an E/M service and identifies polyps in the cervical os. He decides to remove the polyps the same day instead of asking the patient to return.
Because the recent CMS clarification states that you should only append modifier 25 to an E/M code when a procedure has a global period, you should not use modifier 25 in this situation. The code for the biopsy (57500, Biopsy, single or multiple, or local excision of lesion, with or without fulguration [separate procedure]) has a global period of 000.
Where to find global periods: "I check for global periods two ways: the Coding Companion and the National Correct Coding Guide," says Gloria Kirkham, CPC, coding specialist at Womens Health Partnership PC in Carmel, Ind.
"The best resource I have found is the RBRVS," says Melissa Gifford, administrator at Etowah Valley OB/GYN PC in Cartersville, Ga.
Because the E/M service is significant and separately identifiable, you can still report both the E/M code and 57500. You simply do not need modifier 25 appended to the E/M code (such as 99213, Office or other outpatient visit for the evaluation of management of an established patient …).
End result: 57500, E/M service (such as 99213).
Scenario 2: Check FB Removal's Global Days
A patient with an impacted vaginal foreign body presents to the emergency department. Your ob-gyn sees the patient and has difficulty removing the object, so he uses anesthesia to do so.
When you check the global days for the foreign-body removal (57415, Removal of impacted vaginal foreign body [separate procedure] under anesthesia), you'll discover it has 10 global days. This means that this procedure has a global period.
You should report the ED visit separately (using 99281-99285, Emergency department visit ...). Choose a code based on documentation that describes the degree of difficulty removing the foreign body. Make sure your ob-gyn's documentation reflects the actual site, what type of object, if any surrounding areas were affected, and so on. You should append modifier 25 to the ED visit code.
Heads up: The physician must document "a separate identifiable service above and beyond what is considered inclusive in the procedure," says Sherry Wilkerson, RHIT, CCS, CCS-P, coding/compliance manager at CHAN Healthcare Auditors in St. Louis.
The major conclusion of the OIG study was not that modifier 25 was simply inappropriate. "Medical reviewers found that providers did not document the E/M services and/or procedures for 27 percent (116/431) of the sampled claims received from providers," Wilkerson says.
Tip: "If you can get your doctors to dictate a separate note, this will help for documentation purposes as well as any future audit," Kirkham says.
"But keep in mind that just because you use modifier 25 doesn't mean that the insurance company will pay both procedures," Gifford says.
End result: 57415, 99281-99285 with modifier 25 appended.
Scenario 3: Find Out if Pessary Code Warrants Modifier 25
An established patient comes in for her yearly examination, and the ob-gyn decides to fit her with and insert a pessary during the same visit.
You should report 57160 (Fitting and insertion of pessary or other intravaginal support device) in addition to the exam code (such as 99211-99215 or 99395-99397). Because 57160 has no global period, you do not have to append modifier 25.
End result: 57160, 99211-99215 or 99395-99397.
Remember: You do not need to worry about modifier 25 when your ob-gyn performs an E/M service on the same day as a laboratory exam (such as Q0111, Wet mounts, including preparations of vaginal, cervical or skin specimens). Laboratory services are not procedures.