Ask an Auditor: March Edition Exploring Modifier 25

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Evaluation and Management (E/M) services are always under scrutiny by payers. And one of the most common payer audits surrounds Modifier 25. In this podcast, Lori Cox, Elizabeth Hylton, and Charla Prillaman discuss how to properly use this Modifier 25 to ensure documentation compliance and avoid payer audits. Listen and learn:

  • When Modifier 25 is necessary and when should you not use it

  • How to correctly bill an E/M with a minor procedure on the same day

  • What you should do if Modifier 25 appears to be used incorrectly in your organization

  • And more!

To read the full conversation, check out the transcript below.

This podcast is especially helpful for:

  • Outpatient Coders (CPCs)

  • Medical Auditors

  • Medical Coding Educators / Trainers

  • Medical Coding Managers (including Supervisors, Director of Coding, etc.)

  • Medical Billers

  • Medical Billing Managers (including Supervisors, Directors of Billing, etc.)

About the authors

Lori Cox

Lori Cox has over 25 years of experience working in the business side of healthcare. She began her career in patient accounts and then moved into billing and coding for a multispecialty clinic. She was eventually promoted to billing supervisor and then to compliance officer, where she wrote, maintained, and trained employees and providers on fraud and abuse. Currently, Cox works for AAPC Services as Director of Client Engagement, performing audits and education for clients across the U.S. She has spoken at HEALTHCON and regional conferences and has traveled the country educating coders and physicians on complex coding topics such as hem/onc and E/M guidelines. Cox is the past member relations officer for AAPC’s National Advisory Board.

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Full Transcript

Lori: Hello, everyone. Welcome to our very first podcast through AAPC Services. We are excited to bring these to you and hope to do a podcast each month with a different topic. My name is Lori Cox, and I will be the host for today's podcast. We are gonna chat a little bit about Modifier 25 today. I have two experts with me, Charla Prillaman and Elizabeth Hylton, who will be answering questions today on this controversial topic. Hello Charla. Can you tell our listeners a little bit about you?

Charla: Hi, Lori. Thanks for having me today. My name is Charla Prillaman. I have been active in the coding, auditing, reimbursement world for just about 30 years now. And 30 years with Modifier 25. We have researched and looked at lots of questions over the last number of years. I hope I can be helpful in this today's discussion.

Lori: I'm sure you can. And Elizabeth, tell us a little bit about you.

Elizabeth: Hi, Lori. Thanks so much for having me today. I have been in the healthcare arena in one facet or another for about 16 years now. I have done pretty much everything that can be done in a physician's office, from front desk to denial management, to coding, and now I have taken on this role as an auditor with AAPC Audit Services Group. If it's been done, I've seen it.

Lori: So we have got a lot of experience here today, and I'm so happy that both of you could join us. Well, I guess let's just jump right in. So we had some questions submitted, and I will go through a few of those and give you a chance to answer one. I will start with you, Charla. So why don't you tell us what exactly is Modifier 25? And how are we supposed to use it?

Charla: Well, that's a nice broad question. Modifier 25 is, as are all CPT modifiers, a mechanism for communicating information. And when we append a 25 Modifier to a service, if you remember, claims are sent from the sender's computer to the payer's computer and that information is understood by the computers. And the receiving computer sees, air quotes, "sees" a Modifier 25 appended to a service, and it receives the message that the sender understands that the service to which the 25 is appended is two things. It is significant, and it is separate from other procedure that is also reported during the same visit to which it may be bundled. So the definition has those two parts, significant and separate.

Lori: Absolutely. Now I am actually, I've done a lot of Modifier 25 audits myself and we probably need to clarify that Modifier 25 is only used on E/M codes, correct?

Charla: Yes, that's correct.

Lori: It's surprising, how many times I see a 25 on something that's not an E/M code. So we need to make sure that everybody is clear on that aspect. Thank you.

Charla: Welcome.

Lori: Elizabeth, I'll direct this next question to you. If a patient comes in for a preventive medicine service, and has a minor problem such as nasal congestion or a cough, can you add a 99213 with a 25 Modifier to the preventive medicine service?

Elizabeth: This is a pretty common scenario. Typically, self-limited or minor problems will not be billed as a separate E/M service. As Charla said, for Modifier 25 to apply it must be both significant and separately identifiable. So unless this minor problem turns into something that requires an extensive amount of work, prescription management, additional workup, or a significant amount of the provider's time, the answer would probably be no. Not always, but probably.

Lori: Right, right, because we need something a little bit more than just a little spot of eczema, for example, or a very minor problem. We're looking for something a little bit more.

Charla: I would agree, Lori, but let me add, since we're recording this March 16th, the 2020, where we are in the midst of learning more about this COVID-19 virus, I would anticipate that there would be a number of circumstances in the current timeframe where a patient might have, what otherwise, would look like a minor symptom that may be looked at differently by the provider during this pandemic time.

Lori: Right. You are correct. I would, especially if a fever, we've all heard the fever is a cause, right? And there's so much more that we're learning about, during this little time period that we're in here, which actually, that brings me to our next question, Charla. So I'm gonna throw this one at you. We're facing a serious health crisis at the moment, and both CMS and the AMA have released new codes effective immediately for testing of the COVID-19 virus. My understanding is these codes are gonna be processed just like any other lab or pathology codes. So do we need to put a 25 on an E/M for the same day along with these lab codes?

Charla: If they're processed the same way other lab codes are then the answer would be no. So unless we receive other instruction, they will probably fall into what the CCI edits call the XXX category, and a 25 Modifier should not be necessary.

Lori: Right. Now some payers, of course, may have different guidelines, so we always advise to check with your payers on that, but as far as we know an E/M would be separately identifiable from just a lab.

Charla: That's my understanding. Yes.

Lori: All right. Elizabeth, kind of the same scenario, what if the provider prescribes, like, a prescription, such as an antibiotic, would it be appropriate to bill an E/M with my well visit?

Elizabeth: This is going to be situational once again, it's going to depend on how the provider documents. We'll have some questions that will be related to this documentation. Like, was the antibiotic prescribed for an illness, perhaps, that was done as a result of a procedure? Or was it a prophylactic measure to prevent infection after this procedure? You may have to take the documentation back to the provider and get a little bit more information from him or her to determine the purpose of prescribing an antibiotic. But the prescription of the antibiotic itself would not be enough to support Modifier 25 and the medically necessary E/M.

Lori: Right, exactly. And we see that a lot. I think one of the biggest things we do see here at Audit Services is Modifier 25, and it's a preventive medicine or a procedure on the same day, so that was a good point. Charla, what happens if I use a Modifier 25 and I shouldn't have?

Charla: Well, again, you're asking all the questions that have "maybe" answers. Ideally, an unnecessary 25 Modifier would be scrubbed off prior to actual claims transmission, either at the practice in an edit queue or through a clearing house. If, however, an unnecessary 25 Modifier is submitted to a payer, two things can happen. If it is unnecessary, as in there's no bundling between these two procedures, the worst-case scenario is it will bounce out because the computer doesn't recognize that combination and doesn't know what to do with it. Or it could potentially just pay, there's no payment difference, and it would be sort of irrelevant. Now, if a 25 Modifier is appended to an E/M service, indicating that the service was both significant and separate, and it was not significant and separate, you risk being paid funds to which you are not entitled.

Lori: So overuse of this modifier could trigger payer audits.

Charla: Yes.

Lori: Definitely a controversial topic. And that is why I picked some of these questions because there are gray areas in here, and that's what makes it so confusing. And there is no black and white. It's either you have to look for this reason or you have a procedure on the same day. So what does separately identifiable mean? So these are all extremely good questions. Elizabeth, what about 96372, CPT code for administration of a medication. Should it be billed with an office visit, or only the medication?

Elizabeth: This one has a little bit more of a cut and dry answer. If the patient is coming in for only the medication, then no E/M would be billed. Whatever the patient is being managed by the injection for has already been evaluated, there is no significant or separately identifiable E/M service that is performed that will be medically necessary with just an injection.

Lori: Okay. But we could possibly get an E/M if we have a diagnosis that's not related to the injection. And, of course, if the provider does a full visit, right?

Elizabeth: Correct. If there is something that has arisen between times, the patient presents for something that's acute, and the provider goes ahead and addresses that problem out of convenience to the patient, then yes, absolutely, we do have the potential for a medically necessary E/M.

Lori: I agree. Charla, any follow up on that?

Charla: No, I think you've covered all the pertinent points.

Lori: Perfect. We have time for about one more question, and I can actually answer this one. If you're an auditor, and you feel like Modifier 25 is being used incorrectly in your organization what should you do? So for what I would do, and I certainly appreciate Charla and Elizabeth comments on this as well. What should you do if you notice that Modifier 25 appears to be used incorrectly? And the first thing that I would do is look at your data, run reports from your billing software. Look at the modifier, is there a provider that's using it all the time? That is he doing procedures that might be okay, that might not be? Is there a provider who's never using it? What are your denials telling you? Or are you receiving requests from payers when you're using this modifier? Could they possibly be looking at that?

And then, once you've kind of determined any patterns, or you just feel like, I really see that there's a problem here, then you should do an audit. Pull out appropriate sample of claims with the Modifier 25 on it, run an audit, and see what you get from that. If you're determining that you just are not seeing the separately identifiable, you might have to get your higher ups, your compliance, your CFO/CEOs involved and determine what your next steps are. Charla, Elizabeth, anything to add to that?

Charla: Well, just a cautionary note. Just because there are a lot of instances, doesn't mean it's incorrect. So like you said, Lori, I think it's really important that when a person identifies something that kinda looks off the mark, that a deeper dive is taken to see what those facts are. And, of course, for anybody who is operating, and we all should be with a compliance plan in place, there should be guidance that directs the employee to follow a chain of command, if you will, to make sure that it gets the appropriate attention.

Elizabeth: I agree, absolutely. I think it's beneficial to realize, just like the questions that we answered today, there are quite a few situational cases that will come into play. And it may not necessarily be worth, for lack of a better word, pushing the panic button, and realizing, “Oh, there's an issue here, is there really?” Make sure you do your research, make sure you check your payer's most current policies, and understand the documentation, and what's medically necessary and what isn't.

Lori: Absolutely, all very good guidance. Thank you both for answering our questions today. If you have questions on this topic or other topics, please go to our website at www.aapc.com/business. Thank you all for joining us today and stay well.

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