Using Modifier 25 in Otolaryngology: Rewards and Ramifications
Appending modifier 25 (Significant, Separately Identifiable Evaluation and Management Service by the Same Physician or Other Qualified Health Care Professional on the Same Day of the Procedure or Other Service) to an Evaluation and Management (E/M) code, when also billing a minor procedure on the same day, typically results in payment for both services – the reward. But is it correct?
Payors, including the Office of the Inspector General (OIG), have been auditing the proper use of modifier 25 and recouping millions of dollars from otolaryngologists – the ramification. A common misconception is that the E/M code and procedure code are always billed together. That’s just not true. There are times when it is not appropriate to also report the E/M code but bill only the procedure.
We will examine the CPT guidelines about using modifier 25 as well as what Medicare says. Several scenarios frequently encountered in otolaryngology practices will be reviewed. You will have a better understanding of how to correctly use modifier 25 when performed with the common ENT minor procedures including:
- Nasal endoscopy
- Flexible laryngoscopy
- Endoscopic sinus debridement
- Excision of skin lesion, and
- Cerumen removal
You all know Kim to be a smart, practical, ethical and nationally recognized consultant and coding expert. Did you know she’s a former otolaryngology nurse? Kim’s energetic and engaging teaching style makes her a sought-after educator, trainer and speaker. Her nursing background provides her with the ability to understand both the clinical and coding attributes of a procedure. She is an expert in analyzing chart documentation and in reengineering practices to enhance the reimbursement process. Kim has worked at KZA for 25 years consulting with small and large as well as private and academic and employed practices to provide coding education, documentation reviews and revenue cycle process improvement. She understands the complexity of coding and reimbursement issues specific to otolaryngologists – both from a clinical perspective and from a payor side. She not only recognizes the compliance and accuracy necessity of correct coding but also understands what it takes to get paid. You’ll like her!
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