The Office of Inspector General (OIG) released a report in 2005 stating that 35% of claims using modifier 25 did not meet program requirements, resulting in $538 million in improper payments in 2002.
In 2015, Medicare released a compliance newsletter urging providers to review the National Correct Coding Initiative (NCCI) Policy Manual regarding billing E&M services with modifier 25.
For 2018, Anthem reduced the payment of an E&M by 50% when done in conjunction with a wellness exam or other minor procedure. This leaves me thinking, “Are you kidding me?”
The above timeline is somewhat reminiscent of what happened to consultation codes in 2010. Years of notification and education went by before this industry-shocking change signaled that Medicare and some commercial payers would no longer pay for consultation codes. Why? Because approximately 75% of consultation codes submitted to Medicare did not meet all applicable program requirements, which resulted in improper payments.
While the new E&M 50% payment reduction is not said to be the result of overusage, the outcry is similar to when Medicare discontinued paying for consults. If practices continue to improperly report modifier 25 in conjunction with well visits or other minor procedures, will modifier 25 experience the same fate as consultation codes? More importantly, why do we wait until it hits the pocketbook before we begin to notice?
The CPT Manual defines modifier 25 as a “significant, separately identifiable evaluation and management service by the same physician or other qualified health care professional on the same day of the procedure or other service.”
“Significant, separately identifiable” has become lost in translation. For example, Chapter I, Section D of the NCCI Policy Manual, states: “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.” It also states that “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.”
It is important to understand when to append modifier 25 to an E&M in your practice. Ask the question: Is this E&M significant and separately identifiable to the other service being performed?
Examples of improper use of modifier 25 include:
Examples of proper use of modifier 25 include:
Modifier 25 has its place and purpose in medical coding and billing. Just make sure you use it without abusing it, giving payers reasonable cause to perhaps, one day, take it away for good just like consultation codes.
In 2015, Medicare released a compliance newsletter urging providers to review the National Correct Coding Initiative (NCCI) Policy Manual regarding billing E&M services with modifier 25.
For 2018, Anthem reduced the payment of an E&M by 50% when done in conjunction with a wellness exam or other minor procedure. This leaves me thinking, “Are you kidding me?”
The above timeline is somewhat reminiscent of what happened to consultation codes in 2010. Years of notification and education went by before this industry-shocking change signaled that Medicare and some commercial payers would no longer pay for consultation codes. Why? Because approximately 75% of consultation codes submitted to Medicare did not meet all applicable program requirements, which resulted in improper payments.
While the new E&M 50% payment reduction is not said to be the result of overusage, the outcry is similar to when Medicare discontinued paying for consults. If practices continue to improperly report modifier 25 in conjunction with well visits or other minor procedures, will modifier 25 experience the same fate as consultation codes? More importantly, why do we wait until it hits the pocketbook before we begin to notice?
The CPT Manual defines modifier 25 as a “significant, separately identifiable evaluation and management service by the same physician or other qualified health care professional on the same day of the procedure or other service.”
“Significant, separately identifiable” has become lost in translation. For example, Chapter I, Section D of the NCCI Policy Manual, states: “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.” It also states that “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.”
It is important to understand when to append modifier 25 to an E&M in your practice. Ask the question: Is this E&M significant and separately identifiable to the other service being performed?
Examples of improper use of modifier 25 include:
- Patient presents for wart removal. Wart identified and removed.
- Patient presents with open wound due to broken glass. Wound required sutures.
- Patient presents for blood draw. Blood drawn and sent to lab.
- Patient presents for second in a series of Synvisc injections. Injection given.
Examples of proper use of modifier 25 include:
- Patient presents for wart removal. Wart identified and removed. While in the clinic, the patient complained of runny nose and sinus headache accompanied by a fever. The patient was examined, an assessment was made of acute sinus infection, and a prescription was written.
- Patient presents with open wound due to falling on broken glass. Patient complained of dizziness upon standing, which precipitated the fall. She has extremely low blood pressure. The provider sutured the open wound, examined the patient and ordered labs for the dizziness to rule out hypotension or hypoglycemic cause.
Modifier 25 has its place and purpose in medical coding and billing. Just make sure you use it without abusing it, giving payers reasonable cause to perhaps, one day, take it away for good just like consultation codes.
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