Examining the use of modifiers 25 and 27

Payors are becoming more prone to denying evaluation and management (E&M) services as “incidental to another service.”

The appropriateness of a denial and appeal depends on whether the coding rules for both services were met. If the scenario is coded appropriately, practices should definitely appeal. If it was not reported correctly, use it as an educational opportunity, adjust the charge, and document the reason as a coding error for compliance monitoring.

An E&M service can be reported if it is either a significant separate service or a decision for surgery.

Modifier 25
Modifier 25 (significant, separately identifiable E&M service by the same physician on the same day of the procedure or other service) may be appended to an E&M service delivered on the same day as a minor surgical procedure if the E&M service is a significant and separate service.

This typically occurs when a surgeon sees a patient for an evaluation of a condition and decides, as a result of the E&M service, to perform a minor surgical procedure. In this case, modifier 25 can be appended to the E&M service, which can be reported in addition to the minor procedure.

For example, an orthopaedic surgeon is asked to evaluate right knee joint pain in a non-Medicare patient (Fig. 1). The patient’s primary care physician (PCP) has been unsuccessful in treating the patient with conservative therapy. The orthopaedic surgeon performs and documents the E&M service, and diagnoses a joint effusion, which the surgeon decides to aspirate.

In this case, the reason for the encounter was the E&M service, which is significant and should be reported in addition to the joint aspiration. The surgeon also sends a written report to the PCP who requested the consultation.

The surgeon reports the following codes:

• 9924x-25—Significant E&M service, consult, non-Medicare patient
• 20610—Arthrocentesis, aspiration and/or injection; major joint or bursa (eg, shoulder, hip, knee joint, subacromial bursa)

Both services are reportable assuming the documentation supports the services. If the E&M is denied as “incidental,” it can be appealed on the basis that the E&M service was the reason for the visit. The decision to perform the joint aspiration occurred as a result of the E&M service.

Three weeks later, the same patient returns. The knee joint is swollen and the knee is painful and tender. During the examination, the patient asks the surgeon to evaluate his left ankle, which has become increasingly bothersome. The patient is unsure if the problem is related to the right knee problem, if there is another problem, or if the ankle problem is attributable to favoring the left leg because of the knee problem.

The orthopaedic surgeon evaluates the patient’s ankle and right knee and performs another aspiration.

The following codes can be reported:

• 9921x-25—Established patient visit linked to the ankle diagnosis (E&M is now for a separate reason.) The diagnosis code related to the knee effusion should not be linked to the E&M service.
• 20610—Arthrocentesis, aspiration and/or injection; major joint or bursa (eg, shoulder, hip, knee joint, subacromial bursa) The knee effusion diagnosis code should be linked to this procedure code; the ankle diagnosis should not be linked to this code.

Both services are reportable because the E&M service was for a separate condition, and any denial can be appealed on the basis that the E&M service was not inclusive to the surgical procedure.

Modifier 57
Modifier 57 (decision for surgery) is appended to the E&M service when the orthopaedic surgeon evaluates a patient and, as a result of that evaluation, determines that the patient requires a major surgery that will be performed the same or next day. This is the decision-making E&M.

For example, a 25-year-old man with a closed tibial shaft fracture arrives in the emergency department (ED) following a motor vehicle accident. The ED physician conducts an evaluation and requests a consultation from the orthopaedic surgeon. The orthopaedic surgeon evaluates the patient in the ED. After reviewing radiograph and lab results, the surgeon makes immediate plans to take the patient to the operating room for an open reduction and internal fixation (ORIF) of the fracture.

The orthopaedic surgeon reports the consultation service for the E&M in the ED and the ORIF for the surgical intervention. Modifier 57 is appended to the E&M service to indicate it was the decision-making service, as follows:

• 9924x-57—Outpatient consultation (decision for surgery)
• 27759—Treatment of tibial shaft fracture (with or without fibular fracture) by intramedullary implant, with or without interlocking screws and/or cerclage

Action steps

• Ensure all services are accurately reported and supported by documentation.
• Append modifier 25 or 57 as appropriate, based on the payor’s definition of major and minor procedures.
• Construct the appeal to indicate the E&M was the significant, separate, or decision-making visit, which should not be bundled into the surgical services.
• Link diagnosis(es) codes appropriately to support the medical necessity of each service.
• Do not automatically “write-off” any payor denials as “incidental or inclusive” without appeal. If the case was accurately documented and reported, an appeal is warranted.
• Review payor contracts for language indicating that E&M is bundled with a surgical procedure. If this language is found, reconsider the contract.
• Trend payor behavior. If denials consistently track to one or two payors, request a meeting with the Medical Director and outline your concerns. The payor may need to “turn off” an automatic edit that is causing inappropriate, automatic denials.

Mary LeGrand, RN, MA, CCS-P, CPC, is a consultant with KarenZupko & Associates, Inc., and focuses on coding and reimbursement issues in orthopaedic practices.

Global days
Medicare assigns global days to surgical procedure codes, as the following examples show:

• A minor procedure, for the purpose of global days, is a surgical procedure that has a 0- or 10-day global period. Common minor procedures include joint injections, cast/splint applications, wound débridement, and laceration repairs.
• A major procedure, for the purpose of global days, is a surgical procedure that has a 90-day global period. The number of days may vary by payor, but 90-day global periods are the most common and follow Medicare rules. Common major procedures include all major spine procedures; fractures; joint, foot and ankle, and hand surgical procedures; and tumor resections.
• Surgical procedures with no global days are typically indicated on the Medicare Fee Schedule as 000, meaning that the global period concept does not apply. Examples, include codes such as 20550, 20551–20553, 20600–20612. Add-on surgical CPT codes do not have global days either. Because add-on codes are not reported independently, the concept of applying modifier 25 or 57 does not apply to them.