Tag: Modifier 25

Modifier 25 Fact Sheet from Novitas

 Author: Seymore Bones  Published Date: January 28, 2025  Leave a Comment on Modifier 25 Fact Sheet from Novitas

Modifier 25 Fact Sheet

 

Modifier 25 is defined as a significant, separately identifiable evaluation and management (E/M) service by the same physician or other qualified health care professional on the same day of a procedure or other service.

Physicians of the same specialty in the same group practice are considered the same physician; therefore, they must bill and be paid as though they were a single physician.

Appropriate Use

Use modifier 25 with the appropriate level of E/M service.

  • Modifier 25 indicates on the day of a procedure, the patient’s condition required a significant, separately identifiable E/M service, above and beyond the usual pre- and post-operative care associated with the procedure or service performed.
  • E/M service may occur on the same day as a procedure. Medicare allows payment when the documentation supports modifier 25.
  • A minor surgical procedure performed has a global period of 0-day or 10-day listed on the Medicare physician fee schedule (JH) (JL) and meets the definition of modifier 25.

Global Surgery

Global surgery is defined as all necessary services normally furnished by a surgeon before, during, and after a procedure. Medicare payment for a surgical procedure includes pre-operative, intra-operative, and post-operative services routinely performed by the surgeon or by members of the same group with the same specialty.

Do not use modifier 25 when billing for services performed during a post-operative period if related to the previous surgery. Related follow-up examinations by the same provider during the global period of a previous procedure are included in that procedure’s global surgical package.

  • For an unrelated E/M service during the global period of a previous procedure, you may be able to report an appropriate E/M code with modifier 24 (unrelated evaluation and management service by the same physician during a postoperative period) appended.
  • The E/M is for a new problem not related to the patient’s previous complaint or procedure.
  • Append modifier 57 (decision for surgery), rather than modifier 25, if the E/M service prompts the decision to render a major procedure within 24 hours of the E/M service. Major procedure is defined as one with a 90-day global period.

National Correct Coding Initiative (NCCI) Procedure-to-procedure (PTP) edits

The NCCI promotes national correct coding methodologies and controls improper coding leading to inappropriate payment. The PTP code pair edits are automated prepayment edits preventing improper payment when reporting certain codes together for Part B-covered services on the same day by the same physician.

When both correct coding and global surgery edits apply to the same claim by the same physician, we’ll first apply the correct coding edits. Then, we’ll apply the global surgery edits to the correctly coded services

References:

E/M visit complexity add-on HCPS code G2211, 

Effective for dates of service on and after January 1, 2025:

HCPCS code G2211 is payable when an associated office and outpatient (O/O) E/M base code (CPT codes 99202-99205 or 99211-99215) is reported with modifier 25 for the same patient by the same provider and a Part B preventive service, immunization administration, or annual wellness visit service identified in attachment 1 in Change Request (CR) 13705 is also present for the same date of service.

For claims not containing one of the identified services above or dates or service prior to January 1, 2025:

  • Claims will deny when HCPCS code G2211 and an associated office and outpatient (O/O) E/M visit (CPT codes 99202-99205 or 99211-99215) is reported with modifier 25 for the same patient by the same provider on the same date of service:
  • Separately identifiable visits occurring on the same day as minor procedures (such as 0 or 10-day global procedures) have resources sufficiently distinct from costs associated with furnishing stand-alone O/O E/M visits to justify different payment.

References:

Inappropriate use

Avoid denials of claims with an appropriate use of modifier 25

  • Do not report HCPCS code G2211 when modifier 25 is reported on an associated E/M visit (CPT codes 99202-99205 and 99211-99215) for claims not containing a Part B preventive service, immunization administration, or annual wellness visit service or dates of service prior to January 1, 2025.
  • Do not use modifier 25 on HCPCS code G2211.
  • Do not use modifier 25 on CPT code 99211
  • Do not use modifier 25 by a physician other than the physician performing the procedure or physician of the same specialty in the same group practice.
  • Do not use modifier 25 when documentation does not support a significant, separately identifiable E/M service.

References:

How’d You Score?

 Author: Seymore Bones  Published Date: May 22, 2023  Leave a Comment on 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

Both CPT and CMS allow for a problem-oriented visit to be performed on the same calendar day, reported with modifier 25 on the problem-oriented visit.
Medicare Claims Processing Manual, Ch 12. 30.6.1.1.2.H
 
Both CPT and CMS allow for a problem-oriented visit to be performed on the same calendar day, reported 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

 Author: Seymore Bones  Published Date: May 9, 2023  Leave a Comment on 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.