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Otolaryngology Coding Alert

Hone Your Modifier 25 Policies With These Rules

Private payers may drop the modifier requirement for medicine/service claims You finally have a fail-safe policy to stop the nagging doubt over whether you should append modifier 25 to the E/M service on a claim that also involves a medicine code. CPT: Medicine, E/M Claims Don't Need 25 When an allergist performs an office visit that is separate and distinct from a medicine service (meaning a procedure listed in the Medicine section of CPT), -the E/M code does not typically require modifier 25 (Significant, separately identifiable E/M service by the same physician on the same day of the procedure or other service),- says Richard H. Tuck, MD, a nationally recognized coding speaker. -You will not find any language to that effect in CPT or CPT Assistant.-

But your office may be in the habit of automatically entering 25 on all claims for same-day office visits with associated medicine services. Physicians have been increasingly using modifier 25 because payers have recognized the modifier and paid claims coded in that manner, Tuck says. -Thus, the modifier has become used more frequently than rules necessarily dictate.-

Tuck says the following medicine services are among those that CPT does not require to have modifier 25 on the E/M service code (such as 99201-99215, Office or other outpatient visit for the E/M of a patient ...):

- evaluation of patient's use of an inhaler (94664, Demonstration and/or evaluation of patient utilization of an aerosol generator, nebulizer, metered dose inhaler or IPPB device)

- airway inhalation treatment (94640, Pressurized or nonpressurized inhalation treatment for acute airway obstruction or for sputum induction for diagnostic purposes [e.g., with an aerosol generator, nebulizer, metered dose inhaler or intermittent positive pressure breathing (IPPB) device]). CMS Echoes CPT Policy Recently, the Centers for Medicare & Medicaid Services (CMS) backed this less-use policy via a much-needed clarification. New guidance: As of Aug. 20, you should only use modifier 25 when the physician provides a significant and separately identifiable E/M service on the same day as a procedure with a global period, says Jim Collins, CPC, CHCC, president of Compliant MD Inc. in Matthews, N.C.

CMS Transmittal 954 states that modifier 25 -shall be used when the E/M service is above and beyond the usual pre- and postoperative work of a procedure with a global fee period performed on the same day as the E/M service.- Otherwise, -E/M services provided on the date of the procedure are inclusive unless a separately identifiable E/M service is provided on the same day,- says Kathy Pride, CPC, CCS-P, director of consulting and training for QuadraMed in Reston, Va.

You can identify codes that have no global period by looking at column -O- of the 2006 National Physician Fee Schedule Relative Value File. [...]


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