Wiki 25 HELP!!!!

[scrawford1690@gmail.com]

Hey Everyone.

Can someone please explain why a modifier 25 IS needed on a 94010, but not on a 93000?

Or why a modifier 25 IS needed on a 51700 but not on a 51798? I thought it had something to do with the classification, 000 needing a modifier 25 due to pre/post op work, and no modifier 25 on procedures that are XXX, but clearly this does not add up.

 

[sls314]

Yes, sorry e/m without modifier 25 paid with 51798 but a denial for e/m without modifier 25 and 51700

I’m trying to understand where to use the modifier 25, there doesn’t seem to be a rhyme or reason to it

You just need to check the NCCI edits. If there's an edit with the E/M charge and the procedure, then (when appropriate) you'd need a modifier.

 

[amyjph]

Do you mean appending a modifier 25 to an E/M performed at the same time as the procedures above? Is there a specific example of all CPTs that were reported and how they were coded? Are you asking due to denials or rejections?

 

[scrawford1690@gmail.com]

Do you mean appending a modifier 25 to an E/M performed at the same time as the procedures above? Is there a specific example of all CPTs that were reported and how they were coded? Are you asking due to denials or rejections?

Yes, sorry e/m without modifier 25 paid with 51798 but a denial for e/m without modifier 25 and 51700

I’m trying to understand where to use the modifier 25, there doesn’t seem to be a rhyme or reason to it

 

[TThivierge]

Scrawf,
Only use modifier 25 for Eva Mgt CPT codes. Check into HCPCS and CPT manual for how to use them.
Lady T

 

[amyjph]

Agree with Susan.

Some of the MACs have a nice NCCI edit checker you can quickly see: https://www.cgsmedicare.com/medicare_dynamic/j15/ptpb/ptp/ptp.aspx
If your place of work has a product like Encoder or other coding program, they also have NCCI P2P checkers.
You must also check the NCCI manual language as well. https://www.cms.gov/medicare/coding...iative-ncci-edits/medicare-ncci-policy-manual

I have seen very few instances with some payers who may have specific policies where they require a 25 in an abnormal circumstance but this is rare. That would require checking the individual payer policy.

 

[scrawford1690@gmail.com]

You just need to check the NCCI edits. If there's an edit with the E/M charge and the procedure, then (when appropriate) you'd need a modifier.

I have tried this and if I put in a 99203, the 51700 does not come up

 

[scrawford1690@gmail.com]

Agree with Susan.

Some of the MACs have a nice NCCI edit checker you can quickly see: Online Tools
If your place of work has a product like Encoder or other coding program, they also have NCCI P2P checkers.
You must also check the NCCI manual language as well. Medicare NCCI Policy Manual | CMS

I have seen very few instances with some payers who may have specific policies where they require a 25 in an abnormal circumstance but this is rare. That would require checking the individual payer policy.

Thanks so much for your reply. I have tried the ncci checker and when I enter the 99203 e/m code, I cannot find the 51700, 51798 or the 94010 to even see if it says a 0 or a 1.

 

[sls314]

Thanks so much for your reply. I have tried the ncci checker and when I enter the 99203 e/m code, I cannot find the 51700, 51798 or the 94010 to even see if it says a 0 or a 1.

What edit checker are you using?

If you're searching using the CMS spreadsheets, I'd suggest starting with the CPT for your procedure. You don't need to see a list of everything that would have an edit against 99203—that's potentially a very long list and complicates your search unnecessarily. You only want to see what has an edit against your specific procedure—for example, start your search with the 94010, not the 99203.

That said, I suggest using an edit checker on the web instead of trying to navigate the spreadsheets, especially if you're unfamiliar with or uncomfortable with NCCI edits.

If you have access to an online encoder program (EncoderPro, Codify, 3M, FindACode, etc.), it should include an NCCI edit checker.

If you don't have access to an encoder program, many MACs provide them on the website.

Both of these have the capability of filtering results by the minor procedure code:

CGS: Online Tools
FSCO: NCCI lookup tool

 

[amyjph]

I have tried this and if I put in a 99203, the 51700 does not come up

You would want to enter the 51700 (or whatever the procedure is/not the E/M code) as the CPT in the search box, not the E/M. However, there is no edit between these two codes (99203 & 51700). BUT.. was there anything else being done on the DOS. What CPT were billed? Was the only reason the patient was there was for the 51700? There can be other reasons where it would be denied.

There is no edit between 99203 & 51798 either.

There is an edit between 94010 & 99203

Not seeing an edit between 93000 & 99203.

Again, it depends on what else may have been done, if the E/M was separately reportable or not, and who the payer is and if they have a policy (separate from NCCI edits) with regard to the codes being reported separately. It also depends on the CPT being reported. There could be other policies separate from NCCI which would prevent one of these from being billed with an E/M on the same date without a 25. If you have a denial you would need to look into more than just the 25 modifier and what the reason was from the payer as well as policies.

I would also suggest reading the NCCI manual, not just looking at P2P edits. https://www.cms.gov/files/document/medicare-ncci-policy-manual-2024-chapter-11.pdf "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."

Understanding modifier 25 can help too: Modifier 25 Tip Sheet Modifier 25 fact sheet