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Coding Corner: Quiz: Master Modifier -25 in the ED

Check your answers against the experts'

The amount of full-fledged examinations required in the ED can make liberal use of modifier -25 seem appropriate more often than it actually is. Test yourself with this quiz to find out if you know when to bill for the procedure only and when to report the E/M service with modifier -25.
Question 1: The patient presented in the emergency department twice in the same day, and the doctor performed evaluation and management services at both visits. Should you append modifier -25 to the second E/M code you report?
Answer: No, modifier -25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) isn't appropriate in a situation like this. Instead, you should append the more specific modifier -27 (Multiple outpatient hospital E/M encounters on the same date) to the proper ED E/M code (99281-99285), says Caral Edelberg, CPC, CCS-P, president of Medical Management Resources in Jacksonville, Fla., who presented on ED reporting for facilities at the American Academy of Professional Coders National Conference in April.
Because these two visits took place in the same revenue center (450 - Emergency department), make sure you also append modifier -G0, Edelberg says.
Tip: Make sure you stay consistent with the E/M guidelines set up by your facility, says Karen Marsh, RN, MSN, president of Kare-Med Consulting in Jensen Beach, Fla. They must be facility-resource based.
"Most hospitals do not code E/M levels well - even following their own tools - and it amounts to a significant amount of money," Marsh says.

Question 2: A patient presented to the ED after falling off her bike, and experienced both a brief loss of consciousness, and a head wound that required physician repair. Can you report both the E/M code with modifier -25 and the repair code, since the diagnosis code is the same?
Answer: Yes, you can. According to CMS transmittal A-00-40, "Different diagnoses are not required for the reporting of E/M services on the same date." The diagnosis code for which the physician renders an E/M service can be different than the diagnosis code for which the physician performed the diagnostic, medical, surgical, and/or therapeutic medical or surgical procedure.
Question 3: Take a look at these two situations and decide which one requires you to bill for the procedure only - and which also requires an E/M code with modifier -25.
Case 1: One of your physicians is repairing a wound on a diabetic patient, and in the middle of the procedure the patient becomes dizzy. Your staff takes a blood sample and sends it to a lab. The [...]

- Published on 2005-05-17