Our Answers to Questions from the Modifier 25 Webinar

Healthicity received so many great Modifier 25 questions during our recent webinar! They all had slight variations in the details, but most of the questions asked fit into five categories. CJ Wolf, MD, organized his responses below by those five categories.

CJ Wolf, MD, is a highly regarded healthcare professional with more than 20 years of experience in revenue cycle management, practice management, compliance, coding, billing, auditing, and client services. He is a nationally recognized compliance thought leader who has published numerous articles and resources and has been featured at national conferences and events.

Important disclaimer:

Many different entities process claims with medical codes and modifiers. It is important to recognize that the CPT® manual has its own language and guidance regarding Modifier 25. But third-party payors may have their own policies regarding Modifier 25, coverage and reimbursement. It is not practical for the responses below to cover every payor variation or policy. Rather, the responses below are in the context of Medicare guidance and the National Correct Coding Initiative (NCCI). If a commercial payor has its own policy or instructs a provider to use a modifier in a certain way, that instruction is between that particular payor and the provider. You should become familiar with any unique payor policies that affect your practice or organization.

Category 1

Many questions specifically asked if an Evaluation and Management (E&M) code could be reported with a specific procedure code “#####.” For example, some asked if an E&M could be reported on the same day as 95816, 31231, or a wide variety of other specific procedure codes.

The answer is, “it depends.”

First and foremost, to report both codes, it would require both the E&M and the procedure to be medically necessary.

Secondly, the service represented by the E&M needs to be a significant and separately identifiable evaluation and management service. It is important to note that the NCCI manual states:

“Modifier 25 may be appended to E&M services reported with minor surgical procedures (with global periods of 000 or 010 days) or procedures not covered by Global Surgery Rules (with a global indicator of XXX). Since minor surgical procedures and XXX procedures include pre-procedure, intra-procedure, and post-procedure work inherent in the procedure, the provider/supplier shall not report an E&M service for this work. Furthermore, Medicare Global Surgery Rules prevent the reporting of a separate E&M service for the work associated with the decision to perform a minor surgical procedure regardless of whether the patient is a new or established patient.” 

Because the pre-, intra-, and post-procedure work inherent in the procedure varies from procedure to procedure, deciding whether an E&M can be reported for any specific scenario will depend on the details and documentation of that specific situation. This is why it is important to have someone with both clinical knowledge and coding knowledge review or audit a sample of encounters when you are questioning whether it is appropriate to report an E&M on the same day as a procedure.

There will be scenarios where it is appropriate to report both and there will be scenarios when it is not appropriate to report both. Determining when it is, or is not, appropriate is on a case-by-case basis.

The NCCI manual continues:

“In general, E&M services on the same date of service as the minor surgical procedure are included in the payment for the procedure. The decision to perform a minor surgical procedure is included in the payment for the minor surgical procedure and shall not be reported separately as an E&M service. However, a significant and separately identifiable E&M service unrelated to the decision to perform the minor surgical procedure is separately reportable with modifier 25. The E&M service and minor surgical procedure do not require different diagnoses. If a minor surgical procedure is performed on a new patient, the same rules for reporting E&M services apply. The fact that the patient is “new” to the provider/supplier is not sufficient alone to justify reporting an E&M service on the same date of service as a minor surgical procedure. The NCCI program contains many, but not all, possible edits based on these principles.”

This is not to say a separate E&M cannot be reported in addition to a procedure if it is indeed significant and separately identifiable. The NCCI manual provides many examples of this. One example is the administration of chemotherapy. The manual states:

“If a significant separately identifiable evaluation and management service is performed, the appropriate E&M code should be reported utilizing modifier 25 in addition to the chemotherapy code. For an evaluation and management service provided on the same day, a different diagnosis is not required.”

It is possible for a patient to present to an oncology office for management of a cancerous condition that is indeed significant and separately identifiable from chemotherapy administered during the visit. But it is also possible that a patient presents to an oncology office for chemotherapy alone. In this case, a separate E&M should not be reported.

Category 2

Many asked questions similar in theme to the following:

“If a patient is a new patient and the physician performs a procedure, would it be appropriate to report both the new patient E&M code and the procedure?”

The answer is very similar to the explanation provided for Category 1 above. It will depend on whether a separate E&M service was medically necessary, provided, and appropriately documented. Again, there may be scenarios where reporting both an E&M and procedure are appropriate and scenarios where reporting both is not appropriate.   It is important to recognize, however, that just because the patient is new does not automatically mean one could report both an E&M and a procedure. The NCCI manual makes that clear when it states:

“If a minor surgical procedure is performed on a new patient, the same rules for reporting E&M services apply. The fact that the patient is “new” to the provider/supplier is not sufficient alone to justify reporting an E&M service on the same date of service as a minor surgical procedure. The NCCI program contains many, but not all, possible edits based on these principles.”

Category 3

Another common type of question asked was, “Can you report both an initial preventive physical examination (IPPE) or annual wellness visit (AWV) and an E&M during the same encounter?”

The answer is yes, but only if the E&M is significantly and separately identifiable. The Medicare Claims Processing Manual states:

“When the physician or qualified NPP, or for AWV the health professional, provides a significant, separately identifiable medically necessary E/M service in addition to the IPPE or an AWV, CPT codes 99201 - 99215 may be reported depending on the clinical appropriateness of the circumstances. CPT Modifier -25 shall be appended to the medically necessary E/M service identifying this service as a significant, separately identifiable service from the IPPE or AWV code reported (HCPCS code G0344 or G0402, whichever applies based on the date the IPPE is performed, or HCPCS code G0438 or G0439 whichever AWV code applies).”

Category 4

Many wanted to know what constitutes ‘above and beyond’ the pre-, intra-, and post-procedure care, since that is what is required to differentiate between just reporting the procedure and potentially reporting the procedure and an E&M code. Similarly, one person asked, “Is there a website that would show what is pre- and post-services or the standard of care?”

We are not aware of a single website that will explain, for each and every procedure, what would be considered above and beyond the procedure itself. This is why it is critical to have someone with a clinical background and understanding of the procedures to be involved in any reviews of encounters involving Modifier 25.   It is important to point out that this is not just an academic exercise. There are many examples of significant enforcement and financial settlements with government entities for getting Modifier 25 wrong. One health system paid over $1.25 million to resolve allegations that it inappropriately billed E&M services on the same day as infusion services.

In another example, a physician paid over $86,000 relating to allegations of inappropriately billing E&Ms on the same day as COVID-19 vaccination administration.

Category 5

Others asked for clarification between Modifiers 25, 57, and 59. Others asked about which code the modifier should be appended to.

We have already described when it is appropriate to use Modifier 25. The modifier should be appended to the E&M code, not the procedure code.

Modifier 57 is used if a procedure has a global period of 090 days (defined as a major surgical procedure), and an E&M service is performed on the same date of service as a major surgical procedure to decide whether to perform this surgical procedure. In that case, the E&M service is separately reportable with Modifier 57. Other preoperative E&M services on the same date of service as a major surgical procedure are included in the global payment for the procedure and are not separately reportable.

Modifier 59 is described well in the NCCI manual:

“Its primary purpose is to indicate that 2 or more procedures are performed at different anatomic sites or different patient encounters. One function of NCCI PTP edits is to prevent payment for codes that report overlapping services, except in those instances where the services are “separate and distinct.” Modifier 59 shall only be used if no other modifier more appropriately describes the relationships of the 2 or more procedure codes (see Section E for modifiers -X{EPSU}).

The “CPT Manual” defines modifier 59 as follows:

Modifier 59: Distinct Procedural Service: Under certain circumstances, it may be necessary to indicate that a procedure or service was distinct or independent from other non-E/M services performed on the same day. Modifier 59 is used to identify procedures/services, other than E/M services, that are not normally reported together, but are appropriate under the circumstances. Documentation must support a different session, different procedure or surgery, different site or organ system, separate incision/excision, separate lesion, or separate injury (or area of injury in extensive injuries) not ordinarily encountered or performed on the same day by the same individual. However, when another already established modifier is appropriate, it should be used rather than modifier 59. Only if no more descriptive modifier is available, and the use of modifier 59 best explains the circumstances, should modifier 59 be used. Note: Modifier 59 should not be appended to an E/M service.”

Conclusion

These five categories of questions (and the response we’ve provided) represent almost all the questions around Modifier 25.

As a reminder, the answers provided are in the context of Medicare and NCCI guidance. Please review the initial disclaimer at the beginning of this writing for further explanation.

 

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