To 25 or not? Part two

Cracking the Code

Alexander Miller

Dr. Miller, who is in private practice in Yorba Linda, Calif., represents the American Academy of Dermatology on the AMA-CPT Advisory Committee.

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Part one of this column, presented last month, discussed appropriate criteria and general mechanisms for the use of the 25 modifier (which CPT defines as indicating “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”). In this issue I will present specific procedures and examples delineating the process of 25 modifier selection.

When a patient comes in with multiple presenting complaints, all of which require cognitive evaluation, and one of which culminates in a same-day minor procedure such as a destruction or biopsy, it is obvious to both the physician and to a claims reviewer that a substantial evaluation and management (E/M) service well beyond that included in the minor procedure description was delivered. In such a case, one bills for both the procedure and for the separate appropriate level of E/M service with a 25 modifier. There are instances in which it is difficult to determine the level, if any, of separate E/M service delivered. How do a biller and an insurance claims reviewer determine the degree of distinct cognitive service that should qualify for a 25 modifier?

At this year’s AAD Annual Meeting, a Medicare Administrative Contractor Medical Director explained a simple way of determining separate E/M service. One should subtract the entire E/M component included in a given procedure’s valuation and then see what amount of E/M service is left. If nothing is left, then a separate E/M billing is inappropriate. The amount of what is left “stands alone” and is used to determine the level of E/M service to be billed with the 25 modifier. [pagebreak]

In order to subtract the E/M component included in a minor procedure valuation one needs to know what is included in that procedure’s vignette and the pre-service, intra-service, and post-service detailed descriptors. These vignettes and descriptors are not universally known to those responsible for billing and not necessarily intuitively obvious.

Dermatologists most commonly bill E/M services with a 25 modifier along with one or more of the following three procedure code groups: 17000 and 17110 series destruction codes, 11100 biopsy code, and 17260 — 17286 malignant lesion destructions. Below are the CPT descriptions of the pre-, intra-, and post-service work involved in valuing these services.

17000 and 17110 series (destruction)

Pre-service (before the destruction is done) work: includes a review of pertinent medical records data, a discussion of treatment choices, a review of risks of the treatment with the patient, obtaining informed consent, and preparation of necessary equipment.

Intra-service work: inspection and palpation of lesions to establish a diagnosis and to specify size, location, depth, and then the actual destruction with liquid nitrogen freezing.

Post-service work: application of any antibiotic ointment and dressings, if needed, and post-procedure patient and family instructions. Charting and any communication with a referring physician are included in this work. [pagebreak]

11100 (biopsy)

Pre-service: one obtains a pertinent history including previous skin cancer, prior treatments, and sun protection. Indications for the biopsy, expected benefits, and a description of the procedure and its risks are discussed. Consent is obtained and the biopsy tray is prepared.

Intra-service: selection of the optimal biopsy site and lesion inspection and palpation, and then the biopsy procedure itself from start to bandaging.

Post-service: patient instruction on care and follow-up, charting, and communication with any referring physician.

17260 17286 (malignant lesion destructions)

Pre-service: review of pertinent medical records data, followed by discussion of the treatment options and risks. Obtain informed consent and have the necessary procedure tray prepared.

Intra-service: the lesion is inspected, palpated, and its size, location, functional risks, and depth are recorded. Anesthetic is administered and the procedure is done.

Post-service: antibiotic ointment and any dressing are applied and pertinent instructions are given. Recurrence risks and the need for follow-up are discussed. Charting, any operative note report, and communication with a referring physician are included. [pagebreak]

As one can see from the above descriptions, each of the commonly performed dermatologic procedures frequently billed along with a separate 25-modified E/M service includes variable amounts of E/M work. Your challenge in billing is to determine whether the cognitive work done by you is above and beyond that included in the pre-, intra-, and post-service work described for the procedure in question. Below are some examples.

Example 1: An established patient comes in complaining of a steadily enlarging, friable papulonodule on the nose. You obtain a history pertaining to the growth, query the patient concerning previous sun exposure, examine and palpate the lesion, discuss your presumptive diagnosis of a basal cell carcinoma, recommend a biopsy, obtain informed consent, do the biopsy, and instruct the patient on aftercare. You did a significant amount of evaluation and management (E/M) service. In addition to the 11100 biopsy charge you bill for a 99212 established patient visit with an appended 25 modifier.

Answer: Incorrect. Obtaining a pertinent history, examining the lesion, establishing a need for a biopsy, the biopsy itself, and postoperative care discussion are all included in the biopsy code valuation. Once you subtract all the services included in the code valuation, there is no remaining E/M service to bill.

Example 2: An established patient comes in with numerous thick actinic keratoses on sun-exposed skin. You examine the sun-exposed skin, establish and discuss the diagnosis and treatment alternatives, and freeze 18 actinic keratoses. You bill CPT 17004 for the actinic keratoses destruction and 99212 with a 25 modifier for the patient evaluation and examination.

Answer: Incorrect. According to Medicare and the procedure work descriptor, the decision to perform a minor procedure does not justify a separate E/M billing. The examination of the lesions is a component of 17004 code valuation. No work beyond that included in code 17004 was done. [pagebreak]

Example 3: An established patient comes in complaining of a changed mole that, after an examination, you suspect is a melanoma. You obtain a patient and family history of mole atypia and cancer, do a review of systems, and then do a full skin examination, an oral examination, and a palpation of lymph nodal basins. You then excise the mole and bill for an excision along with a 99213 with a 25 modifier to indicate a separate E/M service.

Answer: Correct. There was a medical need for the E/M services provided, and the evaluation, including history, review of systems, full skin and oral cavity examination, and lymph node palpation stand alone as separately identifiable needed services not included in the excision code valuation.

Example 4: An established patient comes in concerned about multiple scaly lesions on the sun exposed face and upper extremities. You examine the lesions, determine that they are actinic keratoses, and destroy eight of them with liquid nitrogen. During the course of the examination the patient mentions that for the past month he has had multiple itchy, scaly areas of the trunk and extremities that are not responsive to home therapy. You take a pertinent history and past medical history and examine the entire skin, diagnosing nummular eczema. You then prescribe appropriate treatment and bill 17000 and 17003x7 for the actinic keratoses destruction and 99212 with a 25 modifier for the evaluation.

Answer: Correct. Two separate entities were treated, one by destruction, and the other by an unrelated cognitive evaluation and management. A stand-alone identifiable E/M service was provided.