Month: May 2023
CMS Efforts to Reduce Prior Auth Burden
Insurers must halve the length of time they take to respond to prior authorization requests
Insurers may no longer require preapproval for emergency behavioral healthcare.
Insurers have to explain denials and publish data on their decisions.
Patients in active treatment who change carriers must be given at least 90 days before the new insurer can require another prior authorization.
Click the below articles for more information.
How’d You Score?
Did you take Betsy Nicoletti’s Quiz on Modifier 25?
Let’s Explore the Facts or Rules Behind the Answers.
#1. The definition and rules for modifier 25 did not change in 2023. “In the March edition of the CPT Assistant it says that while the rules weren’t changed in the 2023 code set “confusion exists regarding its appropriate use.”
#2. What does a modifier added to a CPT or HCPCS code do? The answer is b) Indicates the service or procedure was altered by specific circumstances.
Some modifiers affect payment (like modifier 25) and some are informational only (those appended to teaching physician services). CPT modifiers may be used on HCPCS codes and HCPCS modifiers on CPT codes. A modifier doesn’t change the definition of the code, but indicates that the service or procedure was altered in some way.
#3. When using modifier 25 when reporting an E/M services and a minor procedure, do you need a different diagnosis for the E/M and the Procedure? The answer is NO.
“As such, different diagnoses are not required for reporting of the E/M services on the same date”. CMS says, “If a significant separately identifiable evaluation and management service is performed, the appropriate E&M code should be reported utilizing modifier 25 in addition to the chemotherapy administration or nonchemotherapy injection and infusion service. For an evaluation and Management service provided on the same day, a different diagnosis is not required.” Medicare Claims Processing Manual, CH. 12 30.5.C
#4. When performing a minor procedure, usual preoperative and postoperative activities are included i in the work of the procedure and should not be reported with an E/M service. Which of these activities are considered usual preoperative and postoperative activities? (List may not be complete). Answer is d) All of the above.
The March 2023 CPT Assistant lists the services that are considered part of the procedure—paid for within the fee for the procedure—and should not be counted as a separate E/M.
Pre- and post-operative services typically associated with a procedure include the following and cannot be reported with a separate E/M services code:
• Review of patient’s relevant past medical history,
• Assessment of the problem area to be treated by surgical or other service,
• Formulation and explanation of the clinical diagnosis,
• Review and explanation of the procedure to the patient, family, or caregiver,
• Discussion of alternative treatments or diagnostic options,
• Obtaining informed consent,
• Providing postoperative care instructions,
• Discussion of any further treatment and follow up after the procedure
5) When performing a preventive medicine service or wellness visit, the practitioner also assesses and manages the patient’s chronic conditions, reviews labs, and renews multiple prescriptions. How is this billed? The Answer is b) Preventive medicine or wellness visit and a problem-oriented visit, with modifier 25 on the problem-oriented visit
Medicare Claims Processing Manual, Ch 12. 30.6.1.1.2.H
“When the physician or qualified NPP, or for AWV the health professional, provides a significant, separately identifiable medically necessary E/M service in addition to the IPPE or an AWV, CPT codes 99201 – 99215 may be reported depending on the clinical appropriateness of the circumstances. CPT Modifier -25 shall be appended to the medically necessary E/M service identifying this service as a significant, separately identifiable service from the IPPE or AWV code reported (HCPCS code G0344 or G0402, whichever applies based on the date the IPPE is performed, or HCPCS code G0438 or G0439 whichever AWV code applies).”CPT Professional Ed., 2023, page 32
Cheers to knowledge
Check Your Modifier 25 Knowledge
Our Friend Betsy Nicoletti founder of CodingIntel, says “It’s hard for me to think of a topic that invites so much disagreement between coders and auditors, between practices and payers and with our practitioners.”
She has put together a short little quiz on the topic (below). Tell us how you did.
Recent Comments