FYI MODIFIER -25

 Definition – Modifier -25 is to be used with a Significant, Separately Identifiable Evaluation and Management (E/M) Service by the Same Physician on the Same Day of the Procedure or Other Service.

 Background:  Modifier -25, used to indicate E/M services outside those bundled with a procedure, consistently ranks as the highest billed modifier in both Northern and Southern California .  In claims data for the quarter ending June 30, 2003 , internal medicine (specialty code 11)  topped the list of specialties using modifier -25 in Northern California .  During the same period, podiatry (specialty code 48) was the top user of modifier -25 in Southern California .

 Probe Findings on Modifier -25 (Progressive Corrective Action (PCA) Probe on Modifier -25 by NHIC – California ).  Modifier -25 was selected for this analysis due to concerns regarding potential aberrancy in its use throughout California .  From August 4, 2003 to November 4, 2003 , a modifier -25 across-specialty analysis and probe review was performed on a sample of 200 randomly-selected claims.  

 Probe Review Findings:  Analysis of the claims data for this period indicated a high level of misunderstanding and/or misuse of modifier -25.   The majority of these 200 claims failed to verify ‘same day’ performance of (or claims submitted for) procedures or other services which is a fundamental requirement for the modifier’s use.   The only service reported on the claim form was an E/M code with modifier -25 appended.   Further review confirmed that no other service or procedure was billed by the same provider for the beneficiary on the same day.  Therefore, some providers routinely apply modifier -25 to their evaluation and management service codes in the absence of any procedure, or the service was provided during a global period but not submitted with  the appropriate modifier -24 (see below).

 This initial review confirmed the fact that modifier -25 was being utilized inappropriately, misused, or abused significantly enough to warrant education, more intense review into certain providers’ billing patterns, and the initiation of Progressive Corrective Action Probes as appropriate.

 MODIFIER -25: GENERAL USAGE GUIDELINES

 To properly use the Modifier -25 code, follow these four general guidelines.

 1.  Same day as procedure.   Modifier -25 can only be used to bill a significant, separately identifiable E/M service which occurs on the same day as a primary procedure or service by the same provider.   If  the significant separately identifiable E/M service occurs during a post-procedure global coverage period, but not on the same day of the procedure, use modifier -24.   The physician may claim both the evaluation and management service and the procedure by appending a modifier -25 to the evaluation and management service code. (Modifier -25 should be used with E/M codes only and not with surgery /global codes). 

 2.  Significant, separately identifiable E/M service.  The patient’s medical record documentation is expected to clearly evidence that the evaluation and management service performed and billed was “above and beyond” the usual pre-operative and post-operative care associated with the procedure performed on that same day.   The need to perform an independent evaluation and management service may be prompted by a complaint, symptom, condition, problem, or circumstance which may or may not be related to the procedure (or other service) provided.  As such, different diagnoses from those related to the procedure are not required for reporting of a significant, separately identifiable E/M service performed on the same date.  However, the record should document an important, notable, distinct correlation with signs and symptoms to make a diagnostic classification or demonstrate a distinct problem.  The following case histories provide guidance in classifying a significant, separable E/M service.

 3. Adequate documentation as an E/M service.  E/M services for established visits require two of three key components: history, exam, and decision-making.  Documenting only the evaluation of a separate problem without documenting the management component (what was done about the problem) is incomplete and would be denied as an E/M service, with or without the modifier -25.Appropriate level of E/M service.

 4. An E/M service with the modifier -25 must be coded at the appropriate level (99211-99215) for the E/M service without the modifier -25.  The E/M service should include at least the evaluation of the significant, separately identifiable finding and management (two of the three key components of an E/M service).  Just identifying the finding without decision making does not meet the E/M criteria.  The level of service should only include that significant, separately identifiable finding and management, and not include the usual pre- and post-operative/procedural evaluation (this remember, is included in a global surgery/procedure). 

 SPECIAL USAGE GUIDELINES

 New patient E/M.  A new patient E/M service, as defined by CPT, is, by its very nature, considered to be a significant, separately identifiable evaluation and management service when documentation guidelines for the E/M service are met.  A new patient E/M service does not need to have a modifier -25 appended when a minor procedure/surgery (global period: 000 [same day only] or 010 [10 days]) is performed on the same date.  Therefore when billing any global procedures/surgeries, including foot care codes (CMS dropped the CCI edit), modifier -25 does not need to be appended to the new patient E/M service code.

 Procedure as a follow-up service.  When a procedure (e.g., minor surgery) is performed as a follow-up service, or is  scheduled in advance to be the primary or major service performed during a patient encounter, billing an E/M service is only warranted when there is documentation that a significant, separately identifiable new problem or condition exists.  An example of this is if a patient with actinic keratoses is scheduled to return in two weeks for treatment (destruction) of the lesions.  Unless there is a new and unrelated problem/condition presented for evaluation and management; or there is a significant change in her current problem treatment plan, the primary purpose or major service performed on that scheduled return encounter would be procedural, and not an independent significant, separately identifiable evaluation or management service.  

 E/M on day before a minor procedure (000).  Modifier -25 is not needed if an E/M patient encounter occurred the day before the performance of a minor surgery, since the global period for minor procedures does not include the day prior to the surgery. 

 Services of another physician.  The global surgery policy does not apply to services of another physician who may be rendering services during the pre- and post-operative period unless the physician is a member of the same group and is of the same specialty as the operating physician.

 EXCEPTIONS

 Documentation justification.  Medical records must clearly document information evidencing extra work beyond a procedure’s usual and customary pre-operative service when billing an E/M service with modifier -25.  That supportive documentation must be available upon request with the following exceptions for inpatient dialysis services and critical care visits:

 Inpatient dialysis service.  Inpatient dialysis service(s) (90935, 90937, 90945, and 90947): All E/M services provided on the same day as inpatient dialysis services are denied without review. However, the codes 99221-99223, 99251-99255 and 99238-99239 billed with –25 may be allowed when the respective service was unrelated to the treatment of ESRD and was not and could not have been furnished during the dialysis treatment. Documentation supporting the need of the respective service unrelated to the treatment of end stage renal disease (ESRD), must be submitted with the claim.

 Critical care visits.  When used in conjunction with critical care visits (99291 and 99292) performed during the global period, reimbursement can be made when the following conditions exist:

 The patient is critically ill and requires the constant attention of the physician and

The critical care is unrelated to the specific anatomic injury or general procedure performed.

In lieu of documenting these conditions, ICD-9-CM codes in ranges 800.00-929.9 and 940-959.9 are acceptable (i.e., coded to the highest level of specificity).

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MODIFIER -25 BILLING SCENARIOS

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 Scenario 1:   A patient’s primary care physician writes orders for Dr. Smith, a podiatrist, to see a newly admitted skilled nursing facility (SNF) patient for foot problems.  The podiatrist’s documentation reads as follows: 

SUBJECTIVE: Pain both great toenails. The patient is reporting pain on those two toes with any pressure – shoes, socks, even the bed sheets.  The patient is also reporting constant itching on the bottom of both feet.

OBJECTIVE:  This pleasant, elderly patient is complaining of pain in the great toenails.  The patient states that those nails have been tender for several weeks, steadily increasing in discomfort.  No treatment has previously been performed.  DERM: All nails are discolored and long. The hallux nails are thick, brittle, and severely dystrophic.  There is mild redness surrounding the great toenails.  No drainage is noted.  The patient’s skin is generally thin and shiny.  There is no hair present on the lower extremities.  There is general dryness with scaly reddened skin present along the bottom of both feet. VASCULAR: the pedal pulses are noted as right dorsalis pedis: trace palpable; right PT pulse: 1/4 palpable; left dorsalis pedis: 1/4 palpable; left PT trace palpable.  The patient has mild non-pitting swelling around both ankles.  NEURO: normal sharp/dull sensation with no apparent loss of protective sensation.  Vibratory sensation: deferred.  DTR: deferred. 

ASSESSMENT:  Painful onychomycosis dystrophic hallux nails bilateral with onychia; peripheral vascular disease bilateral; 1-10 nails; dystrophic hallux toenails; onychia hallux bilateral; peripheral vascular disease both feet; chronic tinea pedis bilateral.

Admission diagnosis: UTI, Hx of CVA. 

PLAN: 1) evaluate the patient; 2) debride hallux nails, bilateral 3) trim remaining 8 nails; 4) Rx Loprox cream BID application to bottom of both feet, 5) re-evaluate patient prn.

 

                        ___________________________________________________

 The billing as submitted as follows:

  01/01/03             Subsequent nursing facility care E/M code with modifier -25

01/01/03             CPT 11721 (debridement of nails 6-10)

 

Review of the above medical record indicates the following:

 ·         Performance of a nursing facility E/M service was reasonable and necessary.

·         Debridement of painful mycotic dystrophic of the hallux nails meets Medicare mycotic nail coverage guidelines. 

·         Since the podiatrist is seeing the patient on a first time basis (as a new patient), and a new patient or initial nursing care facility E/M cannot be used, the podiatrist should bill:

 CPT coding should have been:    Subsequent nursing facility care E/M code with modifier -25 is correct.

                                                CPT 11720 – only the great toenails are debrided.          

 ICD-9-CM coding should have been:      ICD-9-CM 110.1 (onychomycosis);

                                                ICD-9-CM 681.11 (onychia);

                                                ICD-9-CM 110.4 (tinea pedis);

                                               

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 Scenario 2:   Ms. Jones has returned for re-evaluation of her heel pain, and possible follow-up cortisone injection.  Ten days prior, the doctor told her that she might require a series of three cortisone injections 10 days apart in order to resolve her symptoms.  Ms. Jones was given her first injection at that time.  During this return visit, she reported that, at first, the right heel hurt, but over the past 4 or 5 days, the pain level had reduced by 60%.   The patient pointed to the area of the right heel that was still tender.  The site was palpated to isolate the area of maximum pain, and a 2^nd injection (3 mg) of Celestone Soluspan was administered to the area near the insertion of the plantar fascia.   The patient was advised to continue her stretching exercises, and keep her weightbearing activities to a minimum.  Impression: plantar fasciitis right heel.  Return to office: 2 weeks for possible 3^rd injection.

  ___________________________________________________

 The billing was submitted as follows:

  02/01/04             E/M code with modifier 25

02/01/04             CPT 20551 (injection tendon origin/insertion)

 Review of the above scenario indicates the following:

 ·         There was no evidence of a separate, significantly identifiable E/M service since:

·         The diagnosis/condition remained with same

·         The treatment was “pre-scheduled” – it was the primary service performed on a patient scheduled to return to the office for follow-up care.

·         There was no significant interval history or examination change, and the follow-up treatment remained unchanged.

 CPT coding should have been:                           

                                                      CPT 20550-RT (the appropriate code for injection plantar fascia)                       

J0702 (betamethasone acetate and betamethasone sodium phosphate, 3 mg)

 ICD-9-CM coding should have been:      ICD-9-CM 728.71 (plantar fasciitis);

                                                            ICD-9-CM 729.5 (pain in limb)

 

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 Scenario 3:  A new patient was referred to an orthopedic surgeon for a consultation.  The patient was complaining of left shoulder pain of one month duration.  The pain was increasing in intensity and limiting according to the patient.  The physician’s documentation indicated that the left and right shoulders were examined, including the performance of a brief range of motion test.   A complete x-ray study of the left should was taken and read as normal.  The orthopedist determined that the patient had a joint inflammation, and administered a cortisone injection.   The documentation information included additional history of present illness, a medical history, a review of systems check-off list which was left blank, his impression and plan (documentation only indicates that “injection given”). 

                        ___________________________________________________

       

The billing was submitted as follows:

 

11/01/03             Consultation E/M code with modifier 25

11/01/03             CPT 73030

11/01/03             CPT 20610 (injection, shoulder)

                

Review of the above scenario indicates the following:

 

·         The consultation E/M service code with a modifier -25 was appropriately billed because consultation series E/M codes do not distinguish whether the patient is new or established, only if the encounter is an initial consultation or and established consultation.  

·         It is expected that the medical record documentation will include the specific type and dosage of steroid that is injected into the joint. 

 

CPT coding should have been:                           

                                                                        Initial consultation E/M with modifier -25

CPT 73030-LT - however this was assessed an overpayment due to lack of documentation of site.                     

CPT 20610-LT – however this was assessed an overpayment due to lack of documentation of dosage administered. 

 

·         In this scenario, had the provider’s medical documentation included the name, dosage, & site of the cortisone injected, the cortisone injection would have been approved as well.

 

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Scenario 4.  An established patient who has not been seen for two years comes into the office complaining of a 1 year history of bleeding hemorrhoids with pain and prolapsed bowel.   The symptoms have been increasing in the last 2 months.  The documentation indicates no significant medical problems other than hemorrhoids.  No significant relief of symptoms with medications, suppositories, or sitz baths is reported.   The patient denies constipation, abdominal pain or other gastrointestinal problems.  She does relate that she had a cardiac catheterization last year, but no symptoms of CAD; no HTN or lung problems.  The patient’s medications included Vioxx 25 mg/day; Premarin 0.025 mg/day; Provera 2-5 mg/day; Dicole bid, Fosamax 20 mg/week; and Anusol DC suppositories prn.  The history and physical examination only gave positive and negative findings regarding the visual rectum and skin surrounding the anus.  The remaining physical exam of other systems only has check-offs in the ‘WNL’ column with no positive or negative written findings.  No digital rectal examination is documented.

 

The provider performed an anoscopy, and documents the findings of:  hemorrhoids – 3 internal @ 3:00 o’clock ; two @ 9:00 o’clock & 12:00 o’clock with thrombosis and bleeding; one fissure at 10:00 o’clock position with moderate degree of rectal prolapse.  Perianal erythema with excoriation; stool – positive for occult blood.

           

The provider scheduled and performed the next morning a fissurectomy, sphincterotomy, and hemorrhoidectomy of the three-thrombosed internal hemorrhoids @ the 3:00 , 9:00 & 12:00 o’clock position.  The patient is given the instruction for the prep. The operative note dated 01/02/03 , confirms this surgery was performed. 

 

                        ___________________________________________________

           

CPT coding should have been:

 

                        08/05/03

                                                            Established E/M service with modifiers -57 and -25

                                                            CPT 46600 (anoscopy; diagnostic)

 

                        08/06/03                     

CPT 46936 (destruction of hemorrhoids, any method; internal and external)

                                                            CPT 46604-51 (anoscopy; diagnostic, with dilation)

CPT 46200-51 (fissurectomy, with or without sphincterotomy)

 

Discussion of the above scenario:

 

08/05/03 : 

·         Modifier -57 indicates that this E/M service resulted in a decision to perform a major surgery within 24 hours of (or prior to) the major surgery with a 90 day global period.  

·         Had the anoscopy not been performed in the office on the afternoon of 08/05/03 , only modifier -57 would have been added to the E/M code. 

·         Modifier -25 is also appended to the E/M service code to indicate that a significant, separately identifiable E/M service and a minor procedure (the diagnostic anoscopy; 00 follow-up days) were performed during the same encounter.

 

08/06/03 :

·         Each of the three procedures performed are billed independently.  Each of the three procedures has a 90-day global period (0090).  

·         The -51 modifier is defined as “Multiple Procedures: When multiple procedures, other than evaluation and management services, are performed at the same session by the same provider, the primary procedure or service may be reported as listed.

·         The additional procedure(s) or service(s) may be identified by appending the modifier ‘-51’ to the additional procedure or service code(s)”.   

 

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Scenario 5.  FOLLOW-UP FOR THE SAME PATIENT IN SCENARIO 4.    09/05/03 .  One month post-op, the patient returned to the same doctor’s office with a complaint of a small amount of rectal bleeding in the past two days after bowel movements.  Although quickly reviewed, the history and physical examination findings were essentially unchanged from the previous evaluation and management service.   No digital rectal examination was performed. The provider determined that the rectum would need to be examined, and performs an anoscoptic exam in the office.  The exam revealed a well-healed scar of the left upper quadrant area of the anal canal, no masses; an internal hemorrhoid was noted at 3:00 o’clock with slight bleeding and a slight degree of rectal prolapse.   The provider was able to make arrangements for the patient to have surgery at the hospital later in the afternoon.  The patient had been NPO, and was told to remain NPO.  She was given instructions for prep.  The operative note indicates that the physician removed the hemorrhoid with an Olympus infrared photocoagulator.  The patient tolerated the procedure well.

 

                        ___________________________________________________

           

CPT coding should have been:

 

                        09/05/03

CPT 46934-78 (destruction of hemorrhoids, any method; internal)

 

Discussion of the above scenario:

·         In this case, the destruction of hemorrhoid procedure would be billed with modifier -78.  Modifier -78 indicates a procedure was performed by the same surgeon during the postoperative period of the initial procedure which was related to the first procedure, and necessitated a return to the operating room. 

·         The examination performed earlier in the day was included in the global period follow-up from the original procedure (i.e., no E/M service should be billed). 

·         The anoscoptic exam was not reimbursed because it involved a related problem occurring within a global period, and it did not involve a return to the operating room.

 

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Scenario 6.   The patient is homebound, and a podiatrist is treating her feet in her home.  This is the third time the podiatrist has seen this patient in the past year.  The last encounter was 61 days before.  The documentation is as follows:  

Date of Service:  03/25/04 .                                

Last Visit: 01/26/04 . 

Primary Care Physician: Dr. Smith  

Date of Last Visit for Diabetes Treatment: 01/14/04

COMPLAINT: Can’t cut nails.  Has returned for scheduled nail care.

HISTORY OF PRESENT ILLNESS:  Patient is a diabetic (diet control) with peripheral vascular disease. 

PAST MEDICAL HISTORY:   Unchanged from the previous visit.  See 01/27/04 record.

MEDICATIONS:                      Unchanged from the previous visit

ALLERGIES:                           Unchanged from the previous visit

HOSPITALIZATION:              Unchanged from the previous visit

PHYSICAL EXAMINATION:  Temperature = 98.6 oral.

Vascular: no pulses palpable bilateral; mild swelling both ankles

Dermological: skin texture & turgor in general – thin & poor; nails are long, discolored, & brittle, 1-5 bilateral.  Neurological:  unremarkable.  Musculoskeletal:  flatfeet; bunion with hallux valgus bilateral; hammertoe deformities 2-5 bilateral.

IMPRESSION:  Diabetic with peripheral vascular disease; long mycotic nails 1-5 both feet

PLAN:  1) evaluate patient

             2) Debride nails 1-10

RESCHEDULE: 2 months

 

Note:  Review of the previous and subsequent medical records on this patient reveals no historical or physical changes from what is noted above.

 .

                        ___________________________________________________

           

The billing was submitted as follows:

                                                            03/25/03

            CPT 99350-25 (home visit for E/M of an established patient

                        comprehensive interval history, comprehensive exam; moderate-service med decision making)      

                        CPT 11721      (debridement of nails 6-10)

 

Review of the above medical record indicates the following:

 

·         The purpose of the encounter was to perform scheduled palliative nail care.

·         There is no evidence of a significant, separately identifiable E/M service.

·         The patient has no changes in her medical history and examination from the previous encounter.

·         The patient has no physical changes.

·         The primary service was procedural, and not evaluation and management.

·         The procedures performed were the same palliative procedures performed 61 days previously.

·         The patient is qualified for routine foot care coverage, and the coding should indicate this.

·         There is no medical necessity for nail debridement; the nails were not thickened, merely long, discolored, and brittle.

·         The procedure performed was reduction of length or nail trimming 1-5 bilateral

 

CPT coding should have been:                                                    CPT 11719-Q8    

 

ICD-9-CM coding should have been:                              ICD-9-CM 110.1 (onychomycosis);

ICD-9-CM 250.70 (diabetes with peripheral vascular disease; type II).

 

Discussion

 

·         This established patient is specifically being seen for routine foot care. 

·         She qualifies for coverage by virtue of her absent pedal pulses bilaterally. 

·         The routine foot care procedure code, in this case, CPT 11719 (trimming of nails 1-10) requires a class finding modifier, -Q8, to indicate coverage supported in the documentation.

·         This patient has been seen on two previous times at home for the same care. 

·         There is essentially no change in her medical history and her physical examination. 

·         There is no evidence of a significant, separately identifiable evaluation and management service performance since the treatment, qualified palliative nail trimming is the primary service (and in this case, the only service) done. 

·         No E/M service billing would be necessary. 

·         Regarding the doctor’s billing, even if an E/M service was warranted, the medical record documentation fails to evidence the level of evaluation and management service billed. 

·         Additionally, the podiatrist billed for debriding nails 6-10, but there is no evidence the nails were thick, no evidence that the nails were or needed to be debrided; no evidence that the nails required anything other than trimming (reducing their length).

 

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Scenario 7.   A patient complains of hearing problems, a problem that seems to occur every 2-3 months.   The physician examined the patient, and determined that the patient's ears are impacted with cerumen, just as they had been 2.5 months ago.  Since this was the patient’s only complaint and didn’t report any other medical problems, the physical exam was limited to the problem area at hand.  The physician removed the impacted cerumen.  The patient was told to contact the office if the problem recurs.

 

                        ___________________________________________________

           

The billing was submitted as follows:

 

06/14/03             CPT 99214-25 (office evaluation and management service)

06/14/03             CPT 69210      (removal impacted cerumen (separate procedure), one or both ears.

 

Review of the above medical record indicates the following:

 

·         There is no evidence of a significant, separately identifiable E/M service.

·         The patient has no noted changes in the medical history and examination.

·         The reported is the same problem previously reported and treated.

·         The primary service was procedural, and not evaluation and management.

 

CPT coding should have been:                                        CPT 69210       

 

ICD-9-CM coding should have been:                  ICD-9-CM 380.4 (impacted cerumen).

                                                            ICD-9-CM V41.2 (problems with hearing).

                                  

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Scenario 8.   An established patient, a retired barber,  came into the physician’s office complaining of abdominal pain, bloating and constipation for the last 2 weeks.  The history indicated no history of alcoholism or street drugs.  The abdomen is rotund. Bowel sounds are present. There is tenderness on palpation in right upper quadrant, but no guarding, liver is not enlarged, no organomegaly.  The remaining physical exam of other systems only has check-offs in the “WNL” column in the medical record with no positive or negative written findings.   The physician orders a flat plate of the abdomen. 

                        ___________________________________________________

            

The billing was submitted as follows:

 

09/03/03             E/M code with modifier -25                               

09/03/03             CPT 74000 (radiologic examination, abdomen; single anteroposterior view)

 

Review of the above medical record indicates the following:

 

·         There is no necessity to add a modifier -25 to the E/M service code since CPT 74000 has no global period.

 

CPT coding should have been:

 

                                                E/M code

                                                CPT 74000       

 

Discussion:

 

·         Adding a modifier -25 to an evaluation and management service code when a diagnostic exam has no global period assigned is minimally viewed as incorrect billing.   A compliant office would note their billing error and use modifier -25 appended to E/M service codes only when it is indicated do so.

 

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Scenario 9.   The patient sustains a severe laceration to the forehead. In addition to the assessment of the laceration which was 8.0 cm in length, the physician performed a comprehensive level history and exam in order to determine if the patient sustained neurological damage before beginning the suturing (layered closure) of the laceration.  The patient is an established patient, who comes into the office.   

                        ___________________________________________________

           

The billing was submitted as follows (and was correct):

 

02/10/04             E/M with modifier-25

02/10/04             CPT 12054 (layer closure of wounds of face; 7.6 cm to 12.5 cm)

 

Discussion:

·         The neurological exam is NOT considered to be a routine preoperative service. 

·         An E/M service can be billed along with the layered closure of the laceration. 

·         This is a new problem.  Modifier -25 should be added to the E/M service code.

 

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Scenario 10.   Mr. Heart comes to see Dr. Stent on March 15, 2004 because of increasing signs and symptoms of heart failure.  After completion of Dr. Stent's evaluation, he appropriately adjusted the patient’s medications, gave dietary advice, etc.  In the course of the evaluation, it is incidentally discovered that the patient’s pacemaker/defibrillator, placed 5 years before, was malfunctioning - and thus Dr. Stent refers the patient to another physician in his group, Dr. Magnet, an electrophysiologist, for evaluation and her opinion regarding the status of the patient.  Mr. Heart goes to the second floor of the building where he sees Dr. Magnet in the pacemaker clinic.  Dr. Magnet, after examining the patient, contacts Dr. Stent to inform him that she will be performing an electronic analysis of a dual chamber pacemaker system with reprogramming.  And she does.

                        ___________________________________________________

           

The billing from the group indicated that Dr. Stent (PIN # XYZ1) claimed the following:

 

03/15/04             E/M code.

 

           

The billing from the group indicated that Dr. Magnet (PIN # XYZ3) claimed the following:

 

03/15/04             CPT 93732 (electronic analysis of dual-chamber system with

             reprogramming).     

                        ___________________________________________________

           

Discussion of the billing      

 

·         It is clear that Dr. Stent performed an evaluation and management (E/M) service on Mr. Heart.   Following the examination, Dr. Stent, who noted a problem with Mr. Heart’s pacemaker, sent him to Dr. Magnet, electrophysiologist, for her opinion. 

·         Dr. Magnet performed a consultation E/M service on the patient, and performed an electronic analysis of the pacemaker system with reprogramming of the pacemaker. Dx code for Dr. Magnet = Pacemaker Malfunction.   

·         Dr. Stent must specifically document in the record that he sent Mr. Heart to Dr. Magnet for consultation for the malfunctioning pacemaker.  The ICD-9-CM Dx code for Dr. Stent should reflect the E/M for CHF.

·         In addition, in the comment section of the billing – biller should add that E/M Consultation by Dr Magnet’s PIN for pacemaker problem *****See upcoming educational article on Concurrent Care***   

 

CPT coding should have been:

 

Dr. Stent:

E/M code w/ a Dx of CHF ICD-9-code

 

Dr. Magnet:

Consultation E/M code with a Dx of Malfunctioning Pacemaker.

CPT 93732 

·         No modifier -25 is necessary because CPT 93732 has no global days).

 

Scenario # 11

 

Mr. Heart comes in with symptoms of increased CHF and chest pain.  Findings justify the management which includes an echocardiogram: Dr. Stent decides to manage this problem with medication. 

 

He bills the following:

 

            E/M SERVICE

 

            93307

            93320

            93325

Review includes the following:

·         The above is correctly coded.  No modifier -25 should be used, since the echocardiogram has no global days. 

 

The same is true for a stress test.   See the CMS Website below for obtaining bundling information.  .  

 

 

SUMMARY

 

Modifier –25 is used when a significant, separate identifiable evaluation and management services is performed and documented in the record.  Remember that the documentation in the record is the only tool that the Contractor can use to determine if the modifier is used correctly.  The documentation for E/M with modifier -25 must include important, weighty, notable, distinct, correlation with signs and symptoms to make a diagnostic classification, or demonstrate a distinct problem.   E/M services for established visits require two of three key components:  history, exam, and decision making.  Documenting only an evaluation of a problem (without the next most important component - the management portion of the service, what was done about the problem), is incomplete and will be denied with or without modifier -25.  The E/M service must be coded at the appropriate service level (99211- 99215).

 

NHIC will be looking at those specialties that are using modifier -25 unnecessarily, especially in cases where the only line item claimed is an E/M service with an improperly appended -25 modifier.   The -25 modifier is also used improperly in the case where the services performed are diagnostic without global days.  NHIC will conduct probes and send educational letters to providers who are attempting to “get their claims paid” when no minor procedures or surgeries are performed on the same day by the same provider.  Following the Progressive Corrective Action approach, follow-up probes will ensue if the provider is not revising his billing practices to comply with the standards explained in this article.

 

The E/M service should be able to stand alone beyond the pre- and post-operative services included in a minor surgery or procedure (global period of 0 to 10 days) performed on the same day.  

 

Providers and billers are responsible to know and understand the usage of relevant modifiers.  The CPT manual lists the modifiers and CMS provides definitions of modifier on their website, http://www.cms.hhs.gov/ in the Medicare Provider Fee Schedule.  Use this CMS website to search for Medicare Provider Fee Schedule and Correct Coding Initiative (CCI) to find those surgeries/procedures that have global periods of 0, 10, and 90 days and any CCI edits.  

 

 

 Global Surgery Codes

 

CODE	DEFINITION
000	ENDOSCOPIC AND MINOR SURGERIES with related preoperative and postoperative relative values on the day of the procedure only included in the fee schedule payment amount; E&M services on the day of the procedure generally not payable * Pre-Op:  E&M Services not payable on the Same Day As The Surgery.                           *Post-Op: None. E&M services are payable on the Day Following Surgery.
010	MINOR SURGICAL PROCEDURE with preoperative relative values on the day of the procedure an postoperative relative values during a 10-day postoperative period included in the fee schedule amount; E&M services on the day of the procedure and during this 10-day Postoperative period generally not payable.  * Pre-Op:  E&M Services not payable on the Same Day As The Surgery.              * Post-Op: E&M Services are not payable up To 10 Days After The Surgery.
090	MAJOR SURGICAL PROCEDURE with a 1-day preoperative period and 90-day postoperative period included in the fee schedule payment amount.                                                                 * Pre-Op:  E&M Services are not payable 1 Day Prior And On The Same Day As The Surgery.                                                    * Post-Op: E&M Services are not payable up To 90 Days After The Surgery.

 

 

References:

Medicare Carriers Manual, Part 3, Chapter XV, Fee Schedule for Physicians’ Service, §15501.1.

Webster’s New Third International Dictionary of the English Language Unabridged, editor in chief, Philip Babcock Gove, Ph.D. and the Merriam-Webster Editorial Staff, Merriam-Webster Inc., Publishers, Springfield , Massachusetts , U.S.A. , 1981, pp. 1123, 2069, & 2116.

Webster’s New World Thesaurus, by Charlton Laird, Warner Communications Company, William Collins + World Publishing Company, Inc., New York, New York, 1974, p. 415.

Medicare B Resource, Vol. # 01-4, December 2001, “A Special Reminder Regarding Use of Modifier 25,” p. 46 – 47.

Your Medicare Newsletter, Vol. # 70, June 1992, “Global Surgical Policy,” p. 12.

Medicare Bulletin Vol. # 98-7, December 1998, “Evaluation and Management Service Modifier 25,” page 5.

2002 Modifiers Made Easy, 2001,Written and updated by Clinical Editors: Terry Santana-Johnson, CCS,CCS-P, CPC Jill Giddens, RHIA, CCS, St. Anthony Publishing/Medicode/Ingenix Companies, p. 215, 186, 164

Your Medicare Newsletter, Vol. # 70, June 1992, “Global Surgical Policy,” p. 12, and Medicare Bulletin Vol. # 98-7, December 1998, “Evaluation and Management Service Modifier 25,” page 5, give a similar definition.

Your Medicare Newsletter, Vol. #99, January 1999, “Modifier –25,”p. 27.

California Codes, Business and Professional Codes, Section 2472. http://www.leg.info.ca.gov//calaw.html.

Foot Procedures Billing Guidelines Medicare Part B, 4/2000, p. 5. Can be found through the NHIC Website at http://www.medicarenhic.com/cal_prov/billing/foot_bill2000.pdf for Southern California Providers or http://www.medicarenhic.com/cal_prov/billing/podgd_2001.pdf for Northern California Providers.

CMS Website for CCI edits may be found at http://www.cms.hhs.gov/physicians/cciedits/ama_agree.asp?URL=/physicians/cciedits/v10_1/ccigrp11v101.zip  .

CMS Website for Bundled Codes may be found at http://www.cms.hhs.gov/physicians/mpfsapp/step0.asp .

4/22/2004 – R2 (minor revisions)

5/13/2004 – R3 (minor revisions)