Wiki Appropriate Use of Modifier 25

[erinal]

Hello all,

I need your opinions and advice about the appropriate use of Modifier 25. This is a common scenario in which my doc will indicate the need for modifier 25. Please let me know your opinion on it.

The patient is referred to us as a new patient for an injection. We schedule the pt, the dr sees the pt, dictates a complete and perfect level 3 or 4 new patient evaluation. The Dr then, during the same session, performs the injection that the pt was referred for. The Dr completes a separate procedure note for the injection. When the superbill is submitted to the billing team the codes selected are 99204-25, 62321. With the information that I have given, do you believe it is appropriate to bill for the initial evaluation separately? It seems to me that the initial eval shouldn't be coded in a case such as this. But the argument from the docs/management is that the workup that is being done in the inital eval warrants the separate billing of the E&M. I agree that they are spending a lot of time visiting w/ the pt and doing the appropriate work involved for their coded level of E&M. But I get nervous because the pt was referred for an injection, and they got that injection that same day. Is the extensive separate documentation for the E&M sufficient to bill? Please help!

 

[thomas7331]

It is impossible to give you a definitive answer on this without actually being able to review some examples of the documentation. In addition, payer policies regarding this may vary. But for purposes of Medicare billing, CMS has made it clear that they consider the initial evaluation on the same day as a minor procedure, including the decision to perform that procedure, as well as any pre- and post-operative E&M related to the procedure itself, to all be included in the global package: The initial evaluation for minor surgical procedures and endoscopies is always included in the global surgery package. Visits by the same physician on the same day as a minor surgery or endoscopy are included in the global package, unless a significant, separately identifiable service is also performed....When the decision to perform the minor procedure is typically done immediately before the service, it is considered a routine pre-operative service and a visit or consultation is not billed in addition to the procedure. The fact that a patient is new to the provider or practice is also not sufficient, in and of itself, to support the use of a modifier 25 for a separate E&M service.

So if you remove those elements related to the decision and preparation for the procedure from the E&M note, the question would have to be asked whether or not there is enough left of the E&M that does not fall into these categories to warrant a separate code with modifier 25. Some things to consider would be: Are there other conditions or comorbidities that the provider has to treat or address that are not part of the procedural work? Is there additional diagnostic work-up or testing needed that is not normally required as part of the procedure? Does the provider have to evaluate and/or treat the underlying condition in addition to the problem for which the procedure is being performed? Is the provider, in addition to deciding on the procedure, creating a longer-term treatment plan that would require more extensive E&M than for a patient just presenting for the procedure itself?

My suggestion, which I often give to coders, is to review and become familiar with the Medicare global surgery policies and any other payer policies that may apply to your practice. Then, with this information in hand, review some of your encounter notes and ask yourself if you (or your provider, if they are willing) could take that note and write a convincing appeal letter to an auditor that could explain clearly why your record supports that there was indeed 'significant and separately identifiable' E&M above and beyond what the policies say are included in the procedure, and that the modifier 25 is supported. You're right to be a little nervous about this if all you have to go on is a statement that the provider is spending a lot of time with the patient because that's not going to be sufficient, but if you're confident that you can explain that the documentation meets the payer's requirements, then you should feel confident about billing the E&M.

Modifier 25 is a confusing and grey area, so hope this helps some.

 

[erinal]

This was extremely helpful, thank you!