This blog was written by Stephanie Krautkramer, Education Director, GCS.
How long has it been since you have read the Centers for Medicare & Medicaid Services (CMS) policy manual on Modifier 25? Or are you like many people individuals who have never looked at the policy on the modifier and were only taught by others? In this hectic world, it is can be difficult to take time to settle in and really look at the guidelines however this is a critical step in the process. In this three part series, modifier 25 is addressed in depth mainly with regards to CMS guidelines and occasionally referenced from individual Medicare Administrative Contractors (MACs).
We all know the description for modifier 25 can be ambiguous and differ depending on which source of information utilized such as, with the Current Procedural Terminology (CPT), CMS, or MACs. Valuable information can be obtained from all sources however they tend to vary.
General items most do know about the 25 modifier:
· It has been on the Office of Inspector General (OIG) watch list for some time
· It is applied only to the Evaluation and Management Service codes for significant and separately identifiable services by the same physician on the same day of a procedure or other services
· Services provided must be documented appropriately in the note for that specific date of service
· It is not used to report a decision to perform surgery
To reduce and eliminate some of the confusion let us look at CMS.
When we start digging with CMS some general specifics are revealed:
· It should only be appended to E/M service codes within the ranges of 92002-94014 (Eye Exams), 99201-99499 (E/M service codes) and HCPCS G0101 and G0175
· The use of modifier 25 would be reported on an E/M service when reported with a procedure code with a status indicator of “S” or “T” when the procedure meets the definition of significant and separately identifiable from the E/M service (Note: 25 modifier claims will still be excepted for procedure codes that do not have a “S” or “T” indicator)
· The documentation must be supported in the patient’s note for the specific DOS to support services provided
Based on the above, one can develop further questions to dig even deeper in an effort to gain clarity. What if you have two CPT codes that are within the E/M code service range that is significant and separately identifiable? What’s the status indicator for the E/M code services? How would this issue be handled appropriately?
Codes 99201-99449 do not have an indicator of “S” or “T,” some have a status indicator of “A” or are services not even covered by Medicare, for example the preventive medicine series 99381-99397. For CMS, this means that when you have two codes with a status indicator of “A”, modifier 25 would not be indicated. For example, if you have a 99221 (initial hospital day) and 99291 (critical care) billed on the same day, by the same provider, CMS does not require a modifier 25 on the 99221, as both the 99221 and the 99291 have status indicators of “A.”
Taking a closer look at Noridian, they instruct to bill the above scenario as follows: “Modifier 25 should be placed on the 99221. It is not necessary on the critical care code.” From this MAC response one can see that they give further local policy on the subject, so in turn, it is always good as a course of action to check with the MAC in addition to CMS when billing for Medicare patients.
When encountering the status indicator “A”, remember the carriers have discretion for coverage decisions when national policy is lacking.
There is, of course an exception to the rule. When billing a medically necessary E/M service (99201-99215) that takes place at the same visit as and Welcome to Medicare Exam (IPPE) or Annual Wellness Exam (AVW). Medicare CPM Chapter 12, Section 30.6.1.1 indicates, “CPT Modifier 25 shall be appended to the medically necessary E/M service identifying this service as significant, separately identifiable service from the IPPE or AWV code reported.” This guideline also instructs not to use any components that were used as part of the IPPE or the AVW toward the components of medically necessary E/M to determine the appropriate level of service for the E/M code.
http://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/downloads/a0180.pdf
https://www.noridianmedicare.com/partb/train/workshops/qa/evaluation_and_management.html
http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/clm104c12.pdf