Wiki Modifier 25 - We are updating our compliance

ahuffine

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We are updating our compliance program and we have come across some discrepancies in regards to -25 use with New Patients and minor procedure with 0 global days.

Referencing the NCCI Policy Manual for Medicare Services, E&M Services page 17 paragraph 5:

If a procedure has a global period of 000 or 010 days, it is defined as a minor surgical procedure. In general E&M services on the same date of service as the minor surgical procedure are included in the payment for the procedure. The decision to perform a minor surgical procedure is included in the payment for the minor surgical procedure and should not be reported separately as an E&M service. However, a significant and separately identifiable E&M service unrelated to the decision to perform the minor surgical procedure is separately reportable with modifier 25. The E&M service and minor surgical procedure do not require different diagnoses. If a minor surgical procedure is performed on a new patient, the same rules for reporting E&M services apply. The fact that the patient is “new” to the provider is not sufficient alone to justify reporting an E&M service on the same date of service as a minor surgical procedure. NCCI contains many, but not all, possible edits based on these principles.

MLN MM2025 updated 11/1/2012

Physicians and qualified nonphysician practitioners (NPP) should use CPT modifier -25 to designate a significant, separately identifiable E/M service provided by the same physician/qualified NPP to the same patient on the same day as another procedure or other service with a global fee period.

AAPC CPT Manual 2016

References the above MLN stating a -25 does not need to be appended on EM for any procedure with a 0 global day.


It seems the MLN conflicts with the NCCI policy re procedures that have 0 global days ie: 11100. Does anyone have any insight into this? Are you coding New E&M with this code?
 
I don't see where NCCI and MLN contradict. Both discuss significant and separately identifiable E&M on same day as a minor surgical procedure. NCCI just goes in more detail stating that not all E&M services performed on the same date are considerred Significant and Separately identifiable.

AMA (I'm assuming AAPC is typo) and CMS don't always agree which is where you will see differences.
 
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Thank you CodingKing for your response.

I guess what we are trying to wrap our minds around because we have some disagreement with a provider: Can we bill a new office visit with a skin biopsy (has NO global period) without a -25?
 
Thank you CodingKing for your response.

I guess what we are trying to wrap our minds around because we have some disagreement with a provider: Can we bill a new office visit with a skin biopsy (has NO global period) without a -25?

NCCI overrides AMA guidelines in the CPT manual.
 
Thank you CodingKing for your response.

I guess what we are trying to wrap our minds around because we have some disagreement with a provider: Can we bill a new office visit with a skin biopsy (has NO global period) without a -25?

This situation comes up often in my office. The best advise I could give you is to take the decision to do the biopsy out of your documentation and remove anything else in the documentation related to the biopsy; if you still have enough to bill a new visit i.e. 99201 then you are golden. Be careful on this as CodingKing is correct regarding CMS and AMA not always seeing "eye to eye".
 
Our experience has been that the commercial payers all want modifier 25 in this situation, whereas our Medicare contractor (Florida) does not want the modifier.
 
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