June 9, 2023 | By Pam Vanderbilt, CPC, CPMA, CPPM, CPC-I, CEMC, CDEO, CPB, CFPC, CRC, CPEDC, CEMA
President, Knowledge Tree Billing, Inc.
You may be thinking, “Really, Pam? Are we talking about modifier 25 again?!?”
Yes! Considering the recent uproar caused by one payer’s plan to implement a policy requiring prepayment review of documentation for all visits billed with 99212-99215, modifier 25, and a minor procedure, it is clear there is still a need to discuss this often-misused modifier.
Although we may not like that payers are creating policies about claims reported with modifier 25 – such as reducing or denying payment – or, like the previously mentioned policy, requiring documentation to be sent with these claims, we must consider WHY they are doing this. It is because WE keep using it incorrectly. By we, I refer to all of us: billers, coders, auditors, providers, etc.
For years there have been reports from authoritative sources such as the OIG (Office of Inspector General) about the risk the overuse of modifier 25 causes to the Medicare trust fund, yet a quick search of the current OIG workplan shows there is an active plan for the OAS (Office of Audit Services) to review dermatologist claims for E/M services reported on the same day as a minor procedure.
Since we continue to use modifier 25 incorrectly, let’s see if we can break it down to the components of its parts to better understand the correct application of the modifier. How better to do that than to start with the definitions of “significant” and “separately”?
Oxford Dictionary defines significant as “sufficiently great or important to be worthy of attention; noteworthy.” Mirriam-Webster provides us with “Having or likely to have influence or effect: IMPORTANT.” and “of a noticeably or measurably large amount.”
Now let’s look at what our trusty dictionaries say about separately. From Oxford, we get “as a separate entity or entities; not together.” Mirriam-Webster says, “in a separate manner or by separate means; not together with someone or something else.”
Using the definitions for significant and separately, we can say Modifier 25 is documentation of an evaluation and management service that is sufficient to be a noticeable amount and worthy of attention that is not together with the components of a minor procedure performed on the same day.
In order to know if the documentation of the E/M service meets this definition, we must understand one more thing. All minor procedures include reimbursement for the pre and post-operative services that are inherent to the procedure. This translates to “some of our E/M work is already included in the payment for the procedure.” This is why modifier 25 requires significant and separately identifiable work for the E/M to be reported.
What work is included in the minor procedure that might preclude our E/M documentation from being significant or separately identifiable? Let’s turn to the recently released CPT®Assistant (Online) 2023;33(11):1-12 for our authoritative answer:
“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.”
If we take some liberties to incorporate our definitions (italicized) into the AMA CPT® definition found in Appendix A of our code books, it will look like this:
It may be necessary to indicate that on the day a procedure or service identified by a CPT code was performed, the patient’s condition required an evaluation and management service that is sufficient to be a noticeable amount and worthy of attention that is above and beyond and not part of the components of a minor procedure performed on the same day. These components include review of patient’s relevant past medical history, exam of the problem area to be treated by the procedure, formulation and explanation of the clinical diagnosis, discussion of the procedure and alternative treatments or diagnostic options with the patient, family, or caregiver, obtaining consent, providing postoperative care instructions, and post-operative discussion of any further treatment and follow up needed. An evaluation and management service that is sufficient to be a noticeable amount and worthy of attention is defined or substantiated by documentation that satisfies the relevant criteria for the respective E/M service to be reported (see Evaluation and Management Services Guidelines for instructions on determining level of E/M service). The E/M service may be prompted by the symptom or condition for which the procedure and/or service was provided. As such, different diagnoses are not required for reporting of the E/M services on the same date. This circumstance may be reported by adding modifier 25 to the appropriate level of E/M service.
One last thing we might consider, if the E&M service was documented in a separate note from the documentation of the procedure, do we have significant documentation of clinically relevant history, exam, and medical decision making not related to the procedure for the E&M note to stand alone? If so, and our documentation supports our newly clarified definition of modifier 25, then we likely support the use of the modifier. If not, only report the procedure. If we start using modifier 25 correctly, maybe the payers will stop implementing policies to mitigate their risk of overpayments.
On a side note, the implementation of the payer policy mentioned at the beginning of this article was postponed right before the implementation date last month. If you are emailing or faxing documentation with your claims to this payer, STOP!