Straight From the Source: Use Modifier 25 the Right Way With CCI Manual Tips

It can be tricky knowing when to append modifier 25 (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).

More specifically it can be tough to determine whether work performed by a provider amounts to a separate E/M (reportable with modifier 25) on the same DOS as another procedure. And the consequences are big. Just ask the eye institute whose modifier 25 use resulted in a $113, 722.10 settlement with the government.

Helpful hint: The National Correct Coding Initiative Policy Manual for Medicare Services (aka CCI manual) offers some guidance in Chapter I.D, which covers E/M services. “Read the manual” are always wise words, but here are some highlights to get you started.

Know When to Break the Usual Rule

The general rule is that you shouldn’t report an E/M on the same date as a minor procedure. Here’s why: Payment for a minor surgical procedure generally includes payment for E/M services on the same date. A minor surgical procedure is one with a global period of 000 or 010 days on the Medicare Physician Fee Schedule. Even the decision to perform surgery is included in the procedure payment. These rules apply whether the patient is new or established, the CCI manual states.

The exception: You may report a significant and separately identifiable E/M, unrelated to the decision to perform surgery. Identify the distinct nature of the E/M service by appending modifier 25 to the E/M code. That modifier shows the E/M is outside the usual work expected for the procedure.

Ready for a Quiz?

Based on what the CCI manual said, see if you can answer this question correctly: The doctor sees a new patient with head trauma and decides the patient needs sutures. After checking allergy and immunization status, the doctor performs the procedure. Does this support reporting a separate E/M in addition to the suture procedure?

The CCI manual (and Medicare Claims Processing Manual, Chap. 12, Section 40.1.C) says no. An E/M is not separately reportable in this scenario.

Opportunity: If you add a medically necessary full neurological exam to our head trauma case, CCI and the MCPM say reporting a separate E/M may be appropriate in that case.

Consider 3 More Modifier 25 Tips

  1. Diagnosis: When you’re deciding whether to report an E/M on the same date as a minor procedure, the CCI manual says the diagnosis can be the same for the procedure and separate E/M. This is in CCI manual Chapter I.D. But let’s step outside of the CCI manual for a moment. Experts advise that although separate diagnoses are not required, they may help demonstrate the distinct nature of the E/M. Caution: You should report different diagnosis codes only if that’s what the documentation supports.
  2. CCI override: Modifier 25 is one of the modifiers the CCI manual lists as a global surgery modifier you may use to override an edit. You’ll find the list of modifiers in Chapter1.E.
  3. Beyond CCI … pay cuts: It’s worth checking your policies to see if using modifier 25 will affect reimbursement. For instance, Independence Blue Cross reimburses E/M codes with modifier 25 at 50 percent of the fee schedule amount in defined circumstances.

What About You?

How do you decide when you may report a separate E/M with modifier 25?

About 

Deborah concentrates on coding and compliance for radiology and cardiology, including the tricky world of interventional procedures, as well as oncology and hematology. Since joining The Coding Institute in 2004, she’s also covered the ins and outs of coding for orthopedics, audiology, skilled nursing facilities (SNFs), and more.

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