Myth Buster: Get Ahead of MPFS 2017 Inspection of 0-Day Global Codes With Mod 25

Tue, Aug 23, 2016 --


2017 MPFS 0 day global modifier 25

A previous post about the 2017 physician fee schedule mentioned that the proposed rule lists 83 services with 0-day globals to review because of the large number of same-day E/Ms being reported with those codes.

If that news got your codey-sense tingling, defeat your audit fears by busting these troublemaking myths.

But first: Speaking of fees, have you heard about the changes planned for the Multiple Procedure Payment Reduction (MPPR) that Medicare applies to the professional component (PC) of certain diagnostic imaging services? Currently, the MPPR results in a 25 percent reduction in the PC payment for additional imaging services beyond the first provided by the same physician to the same patient in the same session. The change, effective Jan. 1, 2017, will adjust that reduction from 25 percent to 5 percent. That means you’ll get paid 95 percent instead of 75 percent!

Now back to the main attraction.

Myth 1: 0-Day Global Period Is the Same as No Global Period

On the Medicare Physician Fee Schedule (MPFS), you can check a code’s global period indicator. There are various options, but here we’re concerned with distinguishing XXX from 000.

An indicator of XXX means the global concept does not apply. Don’t confuse XXX with 000, the indicator for a 0-day postop period. You will see 000 assigned typically to endoscopies and some minor procedures.

Key point: A 0-day global means that there is no pre-operative period and no post-operative days, but Medicare typically does not separately reimburse a visit on the same day as the procedure.

Myth 2: The Decision Visit Is Always Separately Reportable

At some point you may have learned that Medicare does not include the initial evaluation to determine the need for surgery in the global surgical package.

But it’s crucial to note that rule applies to only major surgical procedures, meaning those with a 90-day global. “The initial evaluation is always included in the allowance for a minor surgical procedure,” according to the Medicare Claims Processing Manual (MCPM), Chap. 12, Section 40.1.B.

Bottom line: Report an evaluation and management service by the surgeon on the day of the minor surgery or endoscopy only if the E/M is a significant, separately identifiable service. A beneficiary medical history does not count. The MCPM offers the example of a visit for a full neurological exam on a patient requiring scalp sutures after a head injury.

Append CPT® modifier 25 to the E/M code, such as CPT® code 99213, to indicate the service was above and beyond the usual pre- and postop care.

Myth 3: The 83 Codes in the MPFS Are the Only Ones to Watch

The proposed Medicare fee schedule has called out 83 codes that have high rates of same-day E/Ms. Tip: Law firm Womble Carlyle Sandridge & Rice has posted a list of the codes here.

But don’t spend all your energy watching just these codes. You should follow the rules about when to report a separate E/M any time you report a code with a 0-day global.

Ethical coding is all about reporting the services performed and documented, guided by the official rules of reporting. Inappropriately unbundling an E/M code from a procedure is double-dipping for payment because CMS includes payment for the typical pre- and postop services in the payment for the 0-day procedure code. Keeping tabs on the rules keeps your claims clean and prevents having to refund payers in the future.

How About You?

What are your tips for using modifier 25 correctly?


Deborah works on a wide range of TCI SuperCoder projects, researching and writing about coding, as well as assisting with data updates and tool development for our online coding solutions. Since joining TCI in 2004, she’s covered the ins and outs of coding for radiology, cardiology, oncology and hematology, orthopedics, audiology, and more.

, , , , , , , ,

Leave a Reply