Health Information Management

Get the inside scoop on ED coding and modifiers

APCs Insider, February 15, 2013

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Coders and billers continue to struggle with appending modifiers -25 (significant, separately identifiable evaluation and management [E/M] service by the same physician on the same day of the procedure or other service) and -59 (distinct procedural service). AMA hasn’t changed the rules around use of these modifiers, but people still get it wrong, especially in the fast-paced world of ED coding.

Too often, coders look at modifier -59 as a way to get the organization paid. Modifier -59 will override most edits and will, in fact, often get you paid. That doesn’t mean you should be paid. And that doesn’t mean an auditor won’t take the money back (with interest) at a later date.
 
Coders also sometimes misunderstand when to append modifier -25. Every E/M with a procedure does not qualify for separate payment. Physicians actually need to evaluate a patient before performing a procedure.
 
As Debbie Mackaman, RHIA, CHCO, regulatory ­specialist for HCPro, Inc., in Danvers, Mass, put it, "Just because a patient comes in and breathes your air, dirties your sheets, eats your crackers, and bothers your staff doesn't mean you always get an E/M level in addition to the procedure."
 
I love that explanation. And it’s really a great way to think about modifier -25. Can you justify charging for an E/M in addition to the procedure or are you routinely charging an E/M any time someone breathes your air? Put another way, can you make two distinct notes from the physician documentation: one for the procedure and a completely separate one for an E/M?
 
If yes, append modifier -25 (usually—nothing is ever totally for sure in coding). If no, do not append modifier -25, do not charge a separate E/M, do not collect separate payment.
 
We all know physicians don’t document as well as coders would like. That can be even more pronounced in the ED, where procedures can happen quickly and physicians may not document everything they do. And if it’s not documented, it didn’t happen.
 
Caral Edelberg, CPC, CPMA, CAC, CCS-P, CHC, AHIMA-Approved ICD-10-CM/PCS Trainer, and Joanne M. Becker, RHIT, CCS, CCS-P, CPC, CPCI, are going to explain the correct use of modifiers -25 and -59 in the ED (among other topics) Thursday. Be sure to join us at 1 p.m. Eastern for the 90-minute audio conference, 2013 Facility ED Coding Checkup: Visit Levels, Modifiers, and Observation.
 
You’ll get the inside scoop on appending modifiers -25 and -59, billing observation, and evaluating your E/M criteria. They’ll also explain why your visit levels may be creeping higher (hint: it may be your electronic record) and introduce you to some ICD-10 ED coding concepts. And of course, they’ll answer your questions. So sign up today for your ED coding checkup!



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