星空入口

Advanced Search
Ambulatory Coding & Payment Report
|

Reader Question: Know Your Insurer When Using Modifier -25



Rule Out "Rule Out" Diagnoses

Question: We had an ED physician transfer a patient to observation with chest pain. While under observation, our cardiologist determined the patient actually had gastroesophageal reflux disease (GERD). I understand that Medicare would pay for observation under the chest pain diagnosis, but not for GERD. How do I code this appropriately?

North Dakota Subscriber

Answer: Since you should code to the highest degree of certainty and it is inappropriate to code "rule out" diagnoses in the outpatient setting, you should code this as GERD. While it is often necessary to code the symptoms rather than the final diagnosis in order to justify the tests the ED physician performs, you should only code chest pain as a secondary diagnosis, even though you will not get reimbursed for the observation.

E/M Bundling Depends on Insurer

Question: When we perform a pulmonary study and/or electrocardiogram (EKG) as well as an E/M visit, should we add modifier 25 to the E/M code? I've heard that other ER coders do not add 25. Will their claims get denied?

New York Subscriber

Answer: Unfortunately, there is not a single answer to this. Most insurers will not bundle the E/M service into the EKG (EKGs have no global days and the global package will not apply). However, there are always a few insurers who will bundle any E/M service performed on the same day as any procedure. For those insurers, you will need to append modifier -25. If an insurer doesn't require -25, it is unlikely that they'll deny a claim because of its presence.

Conscious Sedation v. Anesthesia

Question: How do I distinguish between conscious sedation and anesthesia?

Texas Subscriber

Answer: Technically, conscious sedation is a medically controlled state of depressed consciousness during which the patient maintains her airway, reflexes, and ability to respond to verbal stimuli. She is very relaxed, but still awake. Anesthesia services, while often more intense procedures in which the patient may not be able to respond to external stimuli, range broadly over a spectrum of potential states of consciousness. In cases with light analgesics, the patient may be alert and able to converse with the anesthesiologist, so distinguishing between them can sometimes get tricky.

Here are significant distinctions to note when coding the two:

Conscious sedation:

  • Not covered separately by Medicare and many other payers

  • Sedation administered by ED physician

  • Nurse (or an independent trained observer) can monitor patient's status

  • Medical record must include the following: pre-, intra-, and postsedation evaluations, administration of analgesic and monitoring of cardiorespiratory function

  • Not restricted to any CPT code

  • Administered orally, intranasally, rectally, or via IV, IM injection, or inhalation

    Anesthesia:

  • Covered separately by Medicare

  • Second physician administers analgesic and monitors patient's status

  • Requires a modifier from P1 to P6 describing the patient's condition

  • Report time units

  • Usually administered through an endotracheal tube of a mask (general anesthesia), but depending on the nature of the problem, can be given with injection into the spinal cord or peripheral ganglia, injected directly into the affected area, or applied on the skin's surface with a swab.

    Though you cannot bill conscious sedation with anesthesia, in some circumstances, you can report conscious sedation as anesthesia if an ED physician administers it for another doctor performing surgery.

    Mind Your Js and Qs When Coding Injections

    Question: If I administer three different IV drugs via piggyback method in the ED, I assume I should report code Q0081 (Infusion therapy, other than chemotherapeutic drugs, per visit), which I can only charge once. However, the one-charge limit fails to compensate for all the medication, supplies, and labor involved. To ensure proper reimbursement, should I additionally report 90784 (Therapeutic, prophylactic, or diagnostic injection; intravenous) three times? Am I shorting myself to report Q0081?

    Vermont Subscriber

    Answer: If you are billing Medicare, you should bill using the Q codes, because they will cover labor and supplies. You can then bill the medication separately using the appropriate J or Q codes. However, if you are billing an insurer other than Medicare, use 90780 and 90781, because most insurers won't accept Q codes. Again, these codes only cover labor and supplies, so code drugs separately. Coding 90784 would be inappropriate in this case unless a drug is added as a bolus or "push."

     



    • - Published on 2003-04-01
    Read the
    Full Article
    Already a
    SuperCoder
    Member