I work in our software system administration, I am not a daily coder, nor am I a biller...I have recently been brought into discussions about ways to make the billing process easier in our software system but I am concerned with what I am being told by the billing staff...they are telling me that they have created these 'standard practices' of their own to add a modifier 25 to any office visit when specific codes like UAs-81003, Injections-J Codes and Admin codes are on an encounter for specific payers. And in some cases, with some payers they are adding a modifier 25 to the office visit when any other service at all is on that encounter. When I asked about this practice, they tell me "It is the payer's policy" that they will only pay when the modifier 25 is attached, but when I have asked other health centers, I am told that they don't have these issues with these particular payers in most cases. There are a few exceptions. I have brought this concern up to the staff in the billing office and their managers, but it does not appear that anything has changed, they still stand by their "payer policy". Anybody else experience these kinds of denials/issues due to payer policy?
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Wiki Modifier 25 Use
- Thread starter CFINDLING
- Start date
I haven't experienced denials necessarily, but that would definitely add to the admin. burden as usually modifier 25 triggers needing the medical records for a lot of payers. Some pend claims for sure waiting on medical records, also depending on what the the UA or injection is for, I would think they would have a hard time justifying a separate procedure, I would ask them where the payer's policy is located.
amyjph
True Blue
You need to take this to your compliance department and/or higher if this is really what is happening, and the staff/managers of that department will not listen to your concerns.
This has red flags all over it. Like, alert, alert, alert sirens.
www.novitas-solutions.com
"Another example of upcoding related to E&M codes is misuse of Modifier 25. Modifier 25 allows additional payment for a separate E&M service rendered on the same day as a procedure. Upcoding occurs if a provider uses Modifier 25 to claim payment for an E&M service when the patient care rendered was not significant, was not separately identifiable, and was not above and beyond the care usually associated with the procedure."
This has red flags all over it. Like, alert, alert, alert sirens.
Modifier 25 fact sheet
www.novitas-solutions.com
"Another example of upcoding related to E&M codes is misuse of Modifier 25. Modifier 25 allows additional payment for a separate E&M service rendered on the same day as a procedure. Upcoding occurs if a provider uses Modifier 25 to claim payment for an E&M service when the patient care rendered was not significant, was not separately identifiable, and was not above and beyond the care usually associated with the procedure."
I will tell you firsthand that there are some payors who will bundle an E&M visit with anything else done that day, even if not an NCCI edit. I believe it's Aetna that bundles a UA with E&M. So it is very possible the billers are correct about needing -25 on the E&M when billing certain additional services. I will note it's even more likely that the billers have been burned by so many denials by carriers creating their own rules (which do not follow coding guidelines) that the billers have become accustomed to just throwing -25 if there is any doubt of a possible bundle. In fact, it is my hypothesis that this exact reason is a contributing factor to why mod -25 has been flagged as an overused/abused modifier.
From a practical standpoint, if insurance A bundles UAs, insurance B bundles sonograms, insurance C bundles all procedures even if not NCCI edits, insurance D follows NCCI edits but with a few extra codes, and insurance E follows only NCCI, it is very difficult to keep track of every carrier's policy of each procedure with E&M when doing coding. I would hope that a trained coder would add -25 if payor policy bundles ONLY WHEN there actually is a significant, separately identifiable E&M service. A biller however, is less likely to understand the nuances and implications of whether a -25 is appropriate. Particularly if that biller deals with insurance A daily, and of course the visit is significant and separately identifiable from the UA.
To me, these types of situations is exactly when systems software administration can assist. There should be rules built into your system for each payor's exact and correct policy (realizing it may change periodically). So rather than just throw -25 on all E&M, the system alerts (before transmitting claim) that the payor will bundle. An appropriately trained coder (or biller if qualified) should review the individual record to determine IF -25 is appropriate on a case by case basis. There may be some where -25 is NOT appropriate, and you realize they will deny based only on payor policy. There may be some where it truly is an NCCI edit, and then coding should be adjusted by either adding -25 or removing the E&M. There should not be a system built in that -25 is automatically appended without the record being reviewed.
Bottom line is - someone has to do the legwork of getting these policies in writing, and you should then build the edits into your system accordingly.
From a practical standpoint, if insurance A bundles UAs, insurance B bundles sonograms, insurance C bundles all procedures even if not NCCI edits, insurance D follows NCCI edits but with a few extra codes, and insurance E follows only NCCI, it is very difficult to keep track of every carrier's policy of each procedure with E&M when doing coding. I would hope that a trained coder would add -25 if payor policy bundles ONLY WHEN there actually is a significant, separately identifiable E&M service. A biller however, is less likely to understand the nuances and implications of whether a -25 is appropriate. Particularly if that biller deals with insurance A daily, and of course the visit is significant and separately identifiable from the UA.
To me, these types of situations is exactly when systems software administration can assist. There should be rules built into your system for each payor's exact and correct policy (realizing it may change periodically). So rather than just throw -25 on all E&M, the system alerts (before transmitting claim) that the payor will bundle. An appropriately trained coder (or biller if qualified) should review the individual record to determine IF -25 is appropriate on a case by case basis. There may be some where -25 is NOT appropriate, and you realize they will deny based only on payor policy. There may be some where it truly is an NCCI edit, and then coding should be adjusted by either adding -25 or removing the E&M. There should not be a system built in that -25 is automatically appended without the record being reviewed.
Bottom line is - someone has to do the legwork of getting these policies in writing, and you should then build the edits into your system accordingly.
Thank you! This was my thinking as well that we need to get written policies from these payers that say it is their requirement per policy. I do understand their frustration, because it is frustrating to me when they bring me these types of things and I know that a 25 should not be required and all of the other crazy billing rules that various payers make up. Thanks again for your response. It is helpful. I have been building claim edits for them so that charges can be reviewed only, but nothing is set up to auto append the modifier 25, in our software system anyway. There may be some billers that need some additional training.
amyjph
True Blue
At the very least the edit should help stop it for review. However, then sometimes what happens unfortunately, is an individual with little training, not a coder, or does not understand the implications just slaps on a 25 and bypasses the edit anyway to "get it out the door"...
Depending on the software, many have updates that are done at their level which update major payer rules depending on the current guidelines.
Depending on the software, many have updates that are done at their level which update major payer rules depending on the current guidelines.
The hospital system I work for (I code outpatient) as of Jan 2024 we have been told "E&M visit must be significant and separately identifiable from work associated with the procedure; however, new patient E&M codes are excluded from 25 modifier prepayment edits and should not be reported" I honestly don't understand why this is and so hard to break a coding guideline I've been using since the being of time. It might have something to do with a change with Noridian?
amyjph
True Blue
It sounds like it is referring to this: https://med.noridianmedicare.com/web/jeb/topics/modifiers/25
Incorrect Use
- Do not append to E/M codes that are explicitly for new patient only (CPTs 92002, 92004, 99201-99205, 99321-99323 and 99341-99345). These codes are listed as new patient codes and are automatically excluded from global surgery package edit. They are reimbursed separately from surgical procedure and no modifier is required if visit meets significant and separately identifiable guidelines.
Thanks. I guess only the short sentence at the beginning helps when it mentions being able to effectively respond to payment-policy requirements established by other entities. Because I understand the use of Modifier 25 with another procedure and/or EM service, but my problem is when they (payers) are wanting/requiring it on labs, injection codes, etc that are not E/M or procedures. I have just told the staff that my recommendation would be to get the payer policy stating that a modifier 25 is required, if that is really what they are being told.
amyjph
True Blue
I have never heard of any payer wanting a 25 modifier to be appended to anything except an E/M code. What payers are they telling you are requiring this modifier to be appended to a non-E/M code? I think some wires are crossed.