October 3, 2023 | By Shannon DeConda, CPC, CEMC, CEMA, CPMA, CRTT
Have you seen the new AMA Smart Brief on Modifier 25 that was released on August 17th? That’s what I want to talk to you about today. I want to break down the information because I specifically noticed there is a stark difference between the coding policy and the payer policy.
As we go down into the policy (you can take the time to read the background information about why AMA chose to put this payer policy together), what we need to really look at here are the three questions that AMA says if you can answer “yes” to, then you should support an E/M service with a 25 Modifier. The first question asks if the physician performed and documented MDM or time that would support an E/M service. This can be a little problematic because, of course, they did. That goes along with the reason the provider performed the procedure. There’s nothing here that indicates that should be separate and significant; just is it there? Is it a problem-oriented office visit or just the procedure? The second question is could the work to address the complaint or problem stand alone? Well, even if it’s the work to decide to perform the procedure, of course, it could stand alone, in most cases of notes that we audit. That question could infer the wrong reference. The last question is did the physician perform extra work that went above and beyond the typical pre- or postoperative stage? Again, this is a little problematic. You see NCCI policy rules changed in 2021, and again with revisions in 2023 that contradict the statement. They’ve NCCI policy actually removed the ability to use 25 Modifier for work over and above the pre- and postoperative work.
Let’s actually take a look at the NCCI Policy Guide. You will notice that there is a chapter of the Policy Guide that coordinates with every chapter in your CPT book. For today, I’ve used the General Coding Principles because this should apply to all services listed in your CPT book. On page 2, there’s an index and you can click on E/M Services to take you right where you need to go to look at modifier concerns with E/M.
Remember, a 25 Modifier is used on services that have a 0 to 10 global period, so move on down to the section that’s applicable to the global period of 0 to 10 days. If we read through the payer policy, they have made it very clear that the decision to perform that minor surgical procedure is included in the E/M. However, a significant and separately identifiable reason for the E/M can support that service. It goes on to identify that new patients are not exempt to this rule. That’s because, by the way, there are no bundling edits between new patients and CPT codes. Have you ever looked? Again, I challenge you, before you put a 25 Modifier on something, make sure there’s a bundling edit. If there’s no bundling edit, we don’t need the 25 Modifier. So, we go back to the NCCI terminology that states it should be significant and separately identifiable. This is a stark contradiction to what was listed by AMA. Payer policy and coding policy do not always see eye-to-eye, and this is one of those issues that could cause you significant concerns within your organization. You should always be looking at both, and if a payer has a policy that says they utilize NCCI edits, then unfortunately, they should be going by these rules as opposed to AMA’s Smart Brief on 25 Modifier. What would be more helpful here is if payer would get on board and use NCCI. I hear so many practices that say “Yeah, there’s no bundling edit, but this particular insurance still requires a 25 Modifier for this new patient and this procedure.” That’s where we need some corrective policy change. If a healthcare carrier is going to say we follow NCCI edits, then let’s follow them all the way through.
If you have any questions or need any additional information on 25 Modifier, I’ve done a full webinar on 25 Modifier and how to ensure you’re always supporting those services when medically necessary and appropriate. I’m always available to help. Just drop me an email at email@example.com.
Your next steps:
- Become a NAMAS Member to earn those CEUs and take advantage of learning resources, products, and resources!
- Read more blog posts to stay updated on the 2023 Revisions to the 2021 E&M Guidelines.
- Watch Shannon discuss this topic on the NAMAS YouTube channel and subscribe to get notified when new auditing and documentation tips drop!
- Check out the agenda for the 15th Annual NAMAS Auditing & Compliance Conference and register to attend!