January 5, 2024 | By Victoria Moll, CPC, COC, CPMA, CRC, CPFC, CPRC, AAPC Approved Instructor, Fellow CEO, Contempo Coding
The strategic use of Modifier 25, particularly when dealing with same-day procedures within global periods, is essential. Throughout my career, I’ve seen multiple colleagues working on claim edits and would cheerfully apply whatever modifier the system pop-up advised them was needed.
Claim edits are a handy reminder for potentially overlooked modifier applications, but a deepened understanding of where and when to apply them is critical. More and more payors are fighting back at the misuse by simply reducing payments or denying services.
Understanding Global Periods
A global period refers to the span of time around a procedure, typically either 0, 10, or 90 days, during which routine postoperative care, including follow-up visits, is included in the reimbursement for the procedure. The global period concept is vital in determining if Modifier 25 is applicable. Per the Medicare NCCI Policy Manual, modifier 25 should only be applied to an E&M service on the same day as a 0 or 10-day global period procedure.
Defining Significant and Separately Identifiable
The term ‘significant’ can be subjective. At its core, a significant and separately identifiable E&M service goes beyond the routine scope of the associated service. The AMA offers guidelines on what typically constitutes a procedure’s inclusive components, not contributing towards a separate E&M level.
Components usually included in a procedure:
- Review of the 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
“New” has a Nuance
A new patient may take more time to review records and check for issues like potential allergic responses. However, CMS advises in the Chapter 1 NCCI Policy Manual, “If a minor surgical procedure is performed on a new patient, the same rules for reporting E&M services apply. The fact that the patient is “new” to the provider/supplier is not sufficient alone to justify reporting an E&M service on the same date of service as a minor surgical procedure.” This doesn’t preclude the possibility of billing an E&M on the same day for a new patient undergoing a procedure. It simply means that the same guidelines for Modifier 25 apply, and the E&M level must be determined without considering routine aspects of the procedure.
Differentiating Diagnoses
While having different diagnoses for the procedure and the E&M can make the separation more apparent, it isn’t an inherent factor in warranting both services. AMA CPT guidelines do not require multiple diagnoses. However, if the same diagnosis is used, documentation must be crystal clear on what was above and beyond the usual preoperative and postoperative care associated with the procedure or service that was performed on that same date.
Final Thoughts
A well-coded medical record reflects a clear and accurate account of the patient’s encounter, ensuring proper reimbursement and compliance. Documentation to support an E&M and a same-day procedure with modifier 25 must be clear, avoid overlap of services, support the level of service, and be medically necessary.
References: https://www.cms.gov/files/document/medicare-ncci-policy-manual-2024-chapter-1.pdf
https://www.ama-assn.org/system/files/reporting-CPT-modifier-25.pdf
Your next steps:
- Review our webinar on the 25 modifier.
- Check out the NAMAS Reference Cards for the 25 Modifier.
- Make sure you are considering an internal coding validation review for all services billed with a 25 modifier.
DoctorsManagement, LLC is a medical consulting firm that has been around since 1956. They have a division called NAMAS which provides auditing education, resources, training, and services. Their team of experienced auditors and educators are all certified and have at least 10 years of auditing-specific experience. NAMAS instructors are the go-to authorities in auditing and have educated DOJ and RAC auditors, CMS and Medicare Advantage Auditors, and physician and hospital-based auditing professionals. They are proud to have helped so many grow and excel in the auditing and compliance field. NAMAS is also the original creator of the now AAPC-affiliated CPMA credential.
