When RAC contractors start complex reviews of Medicare Part B claims, they will likely hit practices in a weak spot, physicians' use of CPT modifier -25, according to a report by the RAC Monitor.
Automated RAC reviews of Part B claims already have been targeting E/M codes in the global period of surgical procedures, and "I fully expect the RACs to expand this focus to include modified E/M services when complex review of Part B claims commences in earnest," wrote J. Paul Spencer of Fi-Med.
Many physicians do not understand that modifer -25 indicates a significant, separately identifiable E/M service performed on the same day as another procedure or service. "Unless the patient presents with a new problem requiring a workup wholly separate from the scheduled procedure, the billing of an E/M service with a -25 modifier is not appropriate," Mr. Spencer wrote.
On the other hand, a -25 modifier might be allowed for the "doorknob patient," the patient who brings up a wholly different symptom while leaving the exam room. "If the provider documents a separate history, exam and medical decision-making process for the patient’s new problem, it would be appropriate to bill an additional E/M service with the -25 modifier," Mr. Spencer wrote.
Read the RAC Monitor report on CPT codes.
Read more coverage of RACs:
- RACs Face Weak Penalties for Exceeding 60-Day Limit to Review Records
- 3 Ways RAC Audits Differ From Previous Medicare Audits
- 4 Ways Medicaid RACs Could Differ From Medicare RACs
Automated RAC reviews of Part B claims already have been targeting E/M codes in the global period of surgical procedures, and "I fully expect the RACs to expand this focus to include modified E/M services when complex review of Part B claims commences in earnest," wrote J. Paul Spencer of Fi-Med.
Many physicians do not understand that modifer -25 indicates a significant, separately identifiable E/M service performed on the same day as another procedure or service. "Unless the patient presents with a new problem requiring a workup wholly separate from the scheduled procedure, the billing of an E/M service with a -25 modifier is not appropriate," Mr. Spencer wrote.
On the other hand, a -25 modifier might be allowed for the "doorknob patient," the patient who brings up a wholly different symptom while leaving the exam room. "If the provider documents a separate history, exam and medical decision-making process for the patient’s new problem, it would be appropriate to bill an additional E/M service with the -25 modifier," Mr. Spencer wrote.
Read the RAC Monitor report on CPT codes.
Read more coverage of RACs:
- RACs Face Weak Penalties for Exceeding 60-Day Limit to Review Records
- 3 Ways RAC Audits Differ From Previous Medicare Audits
- 4 Ways Medicaid RACs Could Differ From Medicare RACs