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INDEX:
A B C D E F G H I J K L M N O P Q R S T U V W X Y Z

Effective Date: 06/01/2005 Title: Processing -25 Modifiers
Revision Date: 10/02/2009 Document: BI094:00
CPT Code(s): -25 modifier
Public Statement

1)     The -25 CPT modifier is used by physicians to indicate that a significant, separately identifiable Evaluation and Management service has been performed on the same day as a procedure. The only way to confirm that such services have been performed is by auditing medical records.

2)     When the member is seeing a QualChoice network provider, this issue is transparent to the member, since the provider is prohibited by contract from billing the member if QualChoice denies payment for the service so indicated.

3)     When the member is seeing a non-network provider, the member may be held responsible by that provider for all charges not paid by QualChoice.


Medical Statement

1)    The definition of the -25 modifier (from 2009 CPT Standard Edition, page 377) is:

a)    “Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service: 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 a significant, separately identifiable E/M service above and beyond the other service provided or beyond the usual preoperative and postoperative care associated with the procedure that was performed. A significant, separately identifiable E/M service is defined or substantiated by documentation that satisfies the relevant criteria for the respective E/M service to be reported….”

2)    The -25 modifier is appended by the provider to an E/M code, generally an office visit code, when a procedure and an E/M service happen on the same day and the provider intends to indicate that there was a significant, separately identifiable E/M service rendered on that same date. Some claims with a surgical code and an E/M code with a -25 modifier should result in payment for the E/M code. Many should not.

3)    The -25 modifier may also be used when both a preventive visit and a treatment visit are billed on the same date.

4)    For the use of the -25 modifier with injections see BI242.

5)    QualChoice reserves the right to review medical records prior to or following payment for claim lines containing the -25 modifier.

6)    For new patients QualChoice will allow 99201-25 or 99241-25 in conjunction with an office procedure in recognition of the additional time and effort required for a new patient visit. Payment for these codes will not be subjected to review or retrospective audit.

7)    QualChoice has adopted the McKesson ClaimCheck software and will use the determinations in that software (which also includes all CCI edits). For all procedures determined by McKesson ClaimCheck CCI to require a -25 modifier on a concurrently billed E/M code, QualChoice will deny the E/M when billed without the -25 modifier.

8)    In all instances (exception: see 9)c)iv below) when a -25 modifier is appended to an E/M service done on the same date as a procedure, that E/M code will be paid under the presumption that the coding has been done correctly.

9)    QualChoice will perform retrospective, post-payment audits to assess the level of accuracy of coding of claims containing a claim line with a -25 modifier.

a)    Audit frequency will be based on criteria that will include the following:

i)      Frequency of submission of claims with -25 modifier.

ii)     Past performance on audits.

iii)    Participation in a high-risk specialty.

iv)   Random selection

b)    Auditing will be done related both to the appropriate use of the -25 modifier and to the appropriateness of the visit level of the underlying code. In addition, other failures of correct coding on the claim may also be considered in the audit.

c)    Failing an Audit:

i)      If a provider or clinic fails an audit, QualChoice will make an effort to educate that provider or clinic, either by distribution of written materials or by visit.

ii)     A provider who has failed an audit may be asked to repay any overpayment.

iii)    A provider who has failed an audit will be re-audited.

iv)   Repeated failure on auditing of medical records will be considered a reason to “turn off” automated payment of -25 modified claim lines.

d)    Passing an Audit:

i)      A provider or clinic that passes an audit will continue with (or restart) the standard process of having -25 modified claim lines paid on first pass (described in paragraphs 6) and 7) above).

ii)     Repeat audits will be performed periodically, based on the criteria in section a) above.

e)    Request for repayment:

i)      In any audit, if review determines that overpayment was made, the overpayment will be denied and a request for repayment will be made.

f)      Audit Process: the audit process will be conducted as described below:

i)      A sample of recent claims will be selected by QualChoice for the audit. In general, the audit sample will be no more than 20 episodes of care per physician audited. For larger clinics, QualChoice may choose to sample as few as 2 episodes of care per physician, so long as the total sample size is adequate to assess the general coding practices of the clinic (at least 50 total episodes of care).

ii)     A request will be submitted to the provider or clinic for the records related to that visit.

iii)    The office should respond by submitting a copy of the office visit record for each visit selected for the audit. Please note that ALL records created in relationship to the visit should be submitted. If incomplete records are submitted, it may result in a negative determination at the time of audit review.

iv)   This appeal will be reviewed in our Medical Claims Review department and reconsidered based on the clinical notes provided.

v)    The office will be notified of the outcome of this process.


Background

There are attachments to this document to amplify and exemplify appropriate determinations. It is intended that these attachments be freely shared with providers and included in letters explaining -25 modifier claim denials. They are:

Appendix 1: general and dermatological

Appendix 2: Allergy testing

Appendix 3: Infusion Services

Appendix 4: Arthrocentesis Services

Appendix 1: General background

 

The rules governing the use of the -25 modifier are set out in the CPT book. If there were no E/M components included in a procedure code, there would be no reason to have a -25 modifier at all. The CPT book is quite clear that services rendered on the day of surgery relating to the evaluation of the treated problem, assessing the necessity of the procedure, making plans for the procedure, and the care of the patient before, during and after the procedure, are all included in the procedural fee.

 

The definition of the -25 modifier (from 2009 CPT Standard Edition, page 377) is:

“Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure of other service: 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 a significant, separately identifiable E/M service above and beyond the other service provided or beyond the usual preoperative and postoperative care associated with the procedure that was performed. A significant, separately identifiable E/M service is defined or substantiated by documentation that satisfies the relevant criteria for the respective E/M service to be reported….”

 

When a patient presents with a questionable skin lesion, the following elements which could otherwise be counted toward an E/M code should be considered to be included in the price of the procedure:

  • History of present illness to include location, duration and any factors making symptoms worse or better
  • personal history of skin cancer (or of the suspected disease)
  • family history of skin cancer (or of the suspected disease)
  • history of allergies, especially to substances you might use to prepare the skin, anesthetize the lesion, repair the resulting defect or prescribe for postoperative pain relief
  • history of concurrent illness or medication that might influence your choice of anesthetic agent or postoperative analgesic, or your choice of a time or location in which to perform the procedure
  • examination of the area where the skin lesion is located, sufficient to:
    • make a tentative diagnosis
    • determine the general extent of the disease
    • determine whether biopsy is warranted
    • determine what approach to the biopsy is to be preferred

Since these activities are all included in the surgical fee, they are not separately billable as a component of an E/M code billed on the same date.

 

The -25 modifier is to be used to identify significant, separately identifiable E/M services rendered on the same date. An example would be a patient who comes in for a check up on his diabetes and is noted to have a suspicious lesion suggesting a basal cell cancer during the visit for diabetes. In such a case, the evaluation and care of the diabetes would be indicated in an E/M code with the -25 modifier (perhaps 99213-25); the discovery and evaluation of the suspicious lesion are both contained in the surgical code for the biopsy or excision of the lesion (perhaps 11100).

 

This becomes more difficult when both problems relate to the same organ system. For example: A patient with dysplastic nevi is being seen for a regular annual checkup, and, after asking about new lesions (“None that I’ve noticed, Doc.”) and assurance of unchanged general health status, the entire dermis is examined with the result of finding a lesion needing biopsy – in this instance, an appropriate charge for the annual, full body examination for dysplastic nevus syndrome (which might be 99213-25) is warranted in addition to the biopsy charge (which might be 11100).

 

On the other hand, the patient comes in with three skin lesions and the history and physical examination are clearly focused on these lesions. One is biopsied and two are destroyed using liquid nitrogen. For this visit, no additional E/M services have been rendered, so the codes for the biopsy (perhaps 11100) and for the destructions (17000 and 17003) are the only codes billable.

 

This interpretation has been checked with the AMA CPT Inquiry Service and is supported by them.

 

 


 

Appendix 2: Office visits and Allergy Testing

 

The rules governing the use of the -25 modifier are set out in the CPT book. If there were no E/M components included in a procedure code, there would be no reason to have a -25 modifier at all. The CPT book is clear that services rendered on the day of surgery relating to the evaluation of the treated problem, assessing the necessity of the procedure, making plans for the procedure, and the care of the patient before, during and after the procedure, are all included in the procedural fee.

 

The definition of the -25 modifier (from 2009 CPT Standard Edition, page 377) is:

“Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure of other service: 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 a significant, separately identifiable E/M service above and beyond the other service provided or beyond the usual preoperative and postoperative care associated with the procedure that was performed. A significant, separately identifiable E/M service is defined or substantiated by documentation that satisfies the relevant criteria for the respective E/M service to be reported….”

 

Allergy testing services are noted in the CPT book to have some inherent E/M services. When an E/M code is billed with a procedure that has inherent E/M services, the E/M code level must be adjusted to reflect the fact that the E/M services that are inherent in the procedure cannot ALSO be counted as elements of the separate E/M charge. This is what is meant by “a significant separately identifiable E/M service…” in the quote above. For this reason, it is important to consider just what E/M services are inherent in allergy testing services. Since this information is not explicit in the CPT book, this description is intended to assist physicians and coders in a consistent interpretation of the included E/M services in allergy testing.

 

Another source of clues about what E/M services may be contained in a procedural code is an examination of the RBRVS allocation of work RVU to that procedural code. In the case of allergy testing, the work RVU assigned are miniscule to absent. This implies that it is the intent of the RBRVS designers to indicate that very little to no physician activity is to be in the allergy testing codes. Though the CPT book is vague about the extent of E/M services included in allergy testing codes, it is explicit about interpretation and report being included in those codes. Based on the work RVU assignment, it would appear that this should be interpreted as being a complete description of ALL of the E/M services included in these codes.

 We believe a careful clinician would perform at least the following E/M services on the date of allergy testing:

·         An interval history – to determine current level of symptoms and response to previously instituted treatments.

·         A medication history – among other things to ascertain whether the patient has taken any medications that might interfere with getting appropriate results from the testing.

·         An examination of the skin area to which the allergy tests are to be applied to be certain that skin test application is appropriate and that there is not some other intercurrent dermatologic problem that will interfere with interpretation of the testing result.

·         Sufficient review of the medical record or questioning of the patient to allow the clinician to determine which tests should be applied.

·         Application of the tests

·         Reading of the tests

·         Interpretation of the test results

·         Discussion with the patient of the test results

·         Determination of a course of action based on the test results

 

Since these activities are not included in the codes for allergy testing, they should be billed as a separate E/M code with a -25 modifier to indicate that it is recognized that the activities counted toward the E/M code billed are separate and distinct from the activities inherent in the allergy testing itself.


 

Appendix 3: Infusion Services

 

E/M Components of Infusion Services

 

The rules governing the use of the -25 modifier are set out in the CPT book. If there were no E/M components included in a procedure code, there would be no reason to have a -25 modifier at all. The CPT book is quite clear that services rendered on the day of surgery relating to the evaluation of the treated problem, assessing the necessity of the procedure, making plans for the procedure, and the care of the patient before, during and after the procedure, are all included in the procedural fee.

 

The definition of the -25 modifier (from 2009 CPT Standard Edition, page 377) is:

“Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure of other service: 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 a significant, separately identifiable E/M service above and beyond the other service provided or beyond the usual preoperative and postoperative care associated with the procedure that was performed. A significant, separately identifiable E/M service is defined or substantiated by documentation that satisfies the relevant criteria for the respective E/M service to be reported….”

 

Infusion services, like many procedures, have an inherent Evaluation and Management component. This can be somewhat determined by the fact that there is a physician work RVU for each, even though the physician may not actually do any “work” for the infusion itself. The Evaluation and Management service portion includes:

·         Interval history

o   Determine the patient is tolerating treatment

o   Determine there are no significant side effects

o   Ascertain that the patient appears to be responding

·         Brief exam

o   Vital Signs

o   Check on main issue i.e. body part affected

·         Review pertinent lab values

·         Decide on and order infusion solutions, medications and dosages

·         Start or supervise infusion access

·         Supervise infusion

·         Deal with any minor issues arising during infusion

·         Check patient status at the end of the infusion treatment

·         Discuss the day’s treatment with the patient

·         Establish, re-establish or reinforce the next step in the course of treatment

 

The above elements cannot be used to determine if a “separately identifiable” service is performed on the same date, however, if after excluding these E/M components there are sufficient services left that would constitute a “separate” service then the -25 modifier is attached to the appropriate level of E/M code.

 


 

Appendix 4: Joint injection

 

The rules governing the use of the -25 modifier are set out in the CPT book. If there were no E/M components included in a procedure code, there would be no reason to have a -25 modifier at all. The CPT book is quite clear that services rendered on the day of surgery relating to the evaluation of the treated problem, assessing the necessity of the procedure, making plans for the procedure, and the care of the patient before, during and after the procedure, are all included in the procedural fee.

 

The definition of the -25 modifier (from 2009 CPT Standard Edition, page 377) is:

“Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure of other service: 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 a significant, separately identifiable E/M service above and beyond the other service provided or beyond the usual preoperative and postoperative care associated with the procedure that was performed. A significant, separately identifiable E/M service is defined or substantiated by documentation that satisfies the relevant criteria for the respective E/M service to be reported….”

 

A patient who arrives in the office and receives an arthrocentesis for aspiration or for injection of medication, requires a certain amount of evaluation and management service before the procedure is performed. These evaluation and management services are considered by the AMA guidelines to be bundled into the arthrocentesis code. Specifically, the following items would be included in the necessary evaluation/re-evaluation of the patient prior to performance of an arthrocentesis:

·         Interval history of how the patient has done since the last visit, including response to previous treatment and results of diagnostic studies

·         Sufficient past history to assure that the patient will tolerate the needle and the medication to be injected

·         Sufficient review of systems to indicate that there is not a current contraindication to proceeding with an injection of the medication intended

·         Examination of the involved extremity and the involved joint

·         A reflection of sufficient decision making to indicate consideration of whether an arthrocentesis and injection is the appropriate next step in diagnosis and treatment as compared to other possible courses of treatment

·         Conversation with the patient to apprise the patient of the nature of the procedure to be done and expected effects and possible side effects.

 

After removing all entries in the medical record related to these items, if there is sufficient documentation to substantiate an E/M visit, the substantiated visit code should be billed with a -25 modifier to signify that the services represent separately identifiable services performed in addition to the services that are considered to be an inherent part of the arthrocentesis.

 


Application to Products

This policy applies to all health plans and products administered by QualChoice, both those insured by QualChoice and those that are self-funded by the sponsoring employer, unless there is indication in this policy otherwise or a stated exclusion in your medical plan booklet.  Consult the individual plan sponsor Summary Plan Description (SPD) for self-insured plans or the specific Evidence of Coverage (EOC) or Certificate of Coverage (COC) for those plans or products insured by QualChoice.  In the event of a discrepancy between this policy and a self-insured customer’s SPD or the specific QualChoice EOC or COC, the SPD,  EOC, or COC, as applicable, will prevail.  State and federal mandates will be followed as they apply.


Changes: QualChoice reserves the right to alter, amend, change or supplement benefit interpretations as needed.