Pediatric Coding Alert

Think all modifier 25 policies are the same? Think again.

You’ve finally waded through your state’s Medicaid rules to determine exactly how that payer wants you to submit Medicaid claims, so you can start instituting those policies across the board, right? Not so fast. Insurers can dictate completely different rules for how they want your modifier claims submitted.

This is especially true when you’re dealing with private or Medicaid payers. Although 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) is clearly defined in CPT^®, that doesn’t mean individual payers don’t have their own rules. The following three examples will show you how different the regulations can be from one state to the next.

This Insurer Bucks Two Rules

Most practices are aware of two standard uses of modifier 25 usage with procedures: You can only append it to your E/M code when it’s performed with a minor procedure (those with 0 or 10 day global periods), and you should choose modifier 57 (Decision for surgery) instead of 25 if the E/M visit leads to the decision to perform major surgery.

Exception: That’s not quite the policy for a Medicaid provider in Florida. “Amerigroup Florida allows reimbursement for an E/M visit resulting in the decision to perform a major surgery when billed with modifier 25,” the payer states on its website.

Not only is this payer allowing one exception for modifier 25 use (billing it with a major surgery), it’s also saying it can be used instead of modifier 57 when the physician makes the decision for surgery at the E/M visit.

Consider Your Payer for Well, Sick Visit

Every pediatric practice has been there—a patient presents for a preventive medicine visit but also has an illness that you have to separately evaluate. Although coding these visits may be cut and dried when you’re dealing with certain payers, that’s not always the case.

For instance: Amerigroup, a Medicaid administrator for 12 states, advises that you report the preventive visit (such as 99392) without a modifier, followed by the sick visit (99201-99215) with modifier 25 appended to the sick visit code. For instance, you might report 99392 for a preventive medicine evaluation of an established three-year-old patient, followed by 99212-25 for the pediatrician’s evaluation of conjunctivitis he discovers during the wellness visit. This is consistent with standard CPT^® coding.

Not so fast: Other Medicaid payers may not feel the same way. First Choice Healthy Connections, a payer in South Carolina, has a policy stating that modifier 25 “should not be used in an attempt to bill two E/M services on the same date.” This is not consistent with CPT^® instructions.

Some Payers Are Quite Specific

Although each payer has its own modifier 25 policies, you may think that certain procedures can always be billed separately from an E/M code, thanks to modifier 25—but you’d be wrong.

For example, Network Health of Massachusetts specifically says that if you perform skin tag removal or lesion removal, you cannot separately report an E/M service—and using modifier 25 won’t help. “We do not reimburse for modifier 25 if the removal of a lesion is the sole purpose for a provider visit and the examination includes only the evaluation and removal of the lesion,” the company’s policy states. “The evaluation prior to removing the lesion is considered part of the preoperative workup and is not significantly and separately reported.” This also is not consistent with CPT^®.

Get Policies in Writing

Because private insurers and Medicaid providers have very specific rules about how to report E/M visits with modifier 25, always get your policy in writing. If the policy doesn’t address issues such as required modifiers regulations, ask your provider services representative for written documentation of how the payer requires you to deal with modifier use.