Pulmonology Coding Alert

Question: In your December 2004 issue, you advised us to attach modifier -25 to the E/M code when reporting critical care cases. But Medicare and Blue Cross do not allow us to use modifier -25. In fact, when we submit a claim with modifier -25 attached to the E/M, these carriers reject our claims. Do you have any insight as to why this is happening?


New York Subscriber

Answer: NCCI bundles E/M services (such as, subsequent hospital care services, 99231-99233) "bundled" into critical care services. 

Under certain circumstances, you may report these two services on the same day. You may also report a subsequent hospital service with critical care codes, but only if the physician provided subsequent hospital care at the first encounter of the day.
 
If the physician first provided critical care service, you should bill all services reported for that day to the cumulative time for critical care. 

When it is appropriate to report both, you should append modifier -25 (Significant, separately identifiable evaluation and management services by the same physician on the same day of the procedure or other service) to the subsequent service. This "overrides" the NCCI edit.
 
When you append modifier -25, the carrier will request the records via a prepayment letter. The carrier wants to review the sequence of events to ensure that the services are being reported appropriately. 

The records should demonstrate that the patient did not require critical care services until after the initial encounter. If the documentation received by the carrier supports this scenario, the carrier will reimburse you for your claim.

Note: Any insurer who follows NCCI may have the same process in place.