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This article first appeared on RACMonitor.com.
As the RAC contractors ready themselves in the bullpen for their entry into complex review of Part B claims, it is expected that physicians will receive many “blasts from the pasts” as part of the process. To clarify, that is to say that they will be revisited by claims issues that have been clearly identified in the past as problem areas, either as part of a CERT or other type of review.
Modifier usage has been a perennial thorn in the side of both physicians and the auditing parties who love them for at least a decade. Of all CPT modifiers, the twin beasts that are -25 and -59 have wreaked a particularly destructive brand of havoc, based on poor understanding of the modifiers’ definitions and rules for usage. It is the first of these modifiers, indicating a significant, separately identifiable E/M service by the same physician on the same day as a procedure or other service, which I would like to address in this space.
Let’s start from the very beginning. Appendix A of CPT does its very best to clarify when it is best to utilize this modifier. It states “...if the patient’s condition requires 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”, the usage of the modifier is appropriate. It is in the realm of “significant and separately identifiable”, and how this is documented in the medical record, where understanding of the proper usage of this modifier begins to break down.
As a first example, let’s says that an established patient is returning to your practice for a procedure that was scheduled during a previous visit. In this case, unless the patient presents with a new problem which requires a workup wholly separate from the procedure, the billing of an E/M service with a -25 modifier is not appropriate. A decision for surgery has already occurred, meaning that all E/M services on the day of (or the day prior to) the surgery are included in the surgical package. If you are a provider who routinely bills a low-level established patient E/M service on the same date as a surgical procedure, you can more than likely expect a few ADRs from your regional RAC contractor.
One of the most frequent questions I receive regarding the -25 modifier comes from primary care providers. If a primary care provider has a scheduled yearly preventive visit with an established patient they are following at regular intervals for chronic disease management (most often diabetes), can the management of the diabetes be split from the preventive visit?
The main purpose of visits of this type goes back to the scheduling of the encounter. If the patient is presenting for a preventive visit, then the appropriate preventive CPT code based on age will be the reported component. Because of the comprehensive nature of a preventive visit, which by CPT definition should include “an age and gender appropriate history and examination”, it would certainly be surprising if the documentation for a significant and separately identifiable visit can be dictated and clearly recognized in the patient’s medical record.
One exception to this rule would be what I like to refer to as “the doorknob patient”. The provider completes a scheduled preventive visit and believes the visit to be at an end, when suddenly, the patient says “Oh, Doctor, while I’m here…..”. The patient then details a condition that was not mentioned during the course of the preventive visit. If the provider documents a separate history, exam and medical decision making for the patient’s new problem, it would be appropriate to bill an additional E/M service with the -25 modifier. In these cases, breaking out the examination component is going to be a difficult task if an expected full system exam has been undertaken during the course of the preventive visit. Remember that for an established patient visit to be reported for billing, only two of the three key components are necessary to determine level of service. Keeping this in mind will help in the selection of the level of service for the additional E/M code. These rules would also apply to a patient who reports to the physician’s office for a scheduled preventive visit with a previously undocumented illness. Acceptable documentation should include separate history and medical decision making for the new illness in order to be billed as an additional service.
Automated RAC reviews of Part B claims have already established a trend toward the identification of erroneously billed E/M codes in the global period of a surgical procedure. 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.
Learn more about Fi-Med Management.
The information provided should be utilized for educational purposes only. Please consult with your billing and coding expert. Facilities are ultimately responsible for verifying the reporting policies of individual commercial and MAC/FI carriers prior to claim submissions.
This article first appeared on RACMonitor.com.
As the RAC contractors ready themselves in the bullpen for their entry into complex review of Part B claims, it is expected that physicians will receive many “blasts from the pasts” as part of the process. To clarify, that is to say that they will be revisited by claims issues that have been clearly identified in the past as problem areas, either as part of a CERT or other type of review.
Modifier usage has been a perennial thorn in the side of both physicians and the auditing parties who love them for at least a decade. Of all CPT modifiers, the twin beasts that are -25 and -59 have wreaked a particularly destructive brand of havoc, based on poor understanding of the modifiers’ definitions and rules for usage. It is the first of these modifiers, indicating a significant, separately identifiable E/M service by the same physician on the same day as a procedure or other service, which I would like to address in this space.
Let’s start from the very beginning. Appendix A of CPT does its very best to clarify when it is best to utilize this modifier. It states “...if the patient’s condition requires 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”, the usage of the modifier is appropriate. It is in the realm of “significant and separately identifiable”, and how this is documented in the medical record, where understanding of the proper usage of this modifier begins to break down.
As a first example, let’s says that an established patient is returning to your practice for a procedure that was scheduled during a previous visit. In this case, unless the patient presents with a new problem which requires a workup wholly separate from the procedure, the billing of an E/M service with a -25 modifier is not appropriate. A decision for surgery has already occurred, meaning that all E/M services on the day of (or the day prior to) the surgery are included in the surgical package. If you are a provider who routinely bills a low-level established patient E/M service on the same date as a surgical procedure, you can more than likely expect a few ADRs from your regional RAC contractor.
One of the most frequent questions I receive regarding the -25 modifier comes from primary care providers. If a primary care provider has a scheduled yearly preventive visit with an established patient they are following at regular intervals for chronic disease management (most often diabetes), can the management of the diabetes be split from the preventive visit?
The main purpose of visits of this type goes back to the scheduling of the encounter. If the patient is presenting for a preventive visit, then the appropriate preventive CPT code based on age will be the reported component. Because of the comprehensive nature of a preventive visit, which by CPT definition should include “an age and gender appropriate history and examination”, it would certainly be surprising if the documentation for a significant and separately identifiable visit can be dictated and clearly recognized in the patient’s medical record.
One exception to this rule would be what I like to refer to as “the doorknob patient”. The provider completes a scheduled preventive visit and believes the visit to be at an end, when suddenly, the patient says “Oh, Doctor, while I’m here…..”. The patient then details a condition that was not mentioned during the course of the preventive visit. If the provider documents a separate history, exam and medical decision making for the patient’s new problem, it would be appropriate to bill an additional E/M service with the -25 modifier. In these cases, breaking out the examination component is going to be a difficult task if an expected full system exam has been undertaken during the course of the preventive visit. Remember that for an established patient visit to be reported for billing, only two of the three key components are necessary to determine level of service. Keeping this in mind will help in the selection of the level of service for the additional E/M code. These rules would also apply to a patient who reports to the physician’s office for a scheduled preventive visit with a previously undocumented illness. Acceptable documentation should include separate history and medical decision making for the new illness in order to be billed as an additional service.
Automated RAC reviews of Part B claims have already established a trend toward the identification of erroneously billed E/M codes in the global period of a surgical procedure. 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.
Learn more about Fi-Med Management.
The information provided should be utilized for educational purposes only. Please consult with your billing and coding expert. Facilities are ultimately responsible for verifying the reporting policies of individual commercial and MAC/FI carriers prior to claim submissions.