Pediatric Coding Alert

You’ll need a new diagnosis for E/M payment from Tufts.

Most pediatric practices use modifier 25 multiple times a day to let insurers know that they deserve separate payment for E/M visits done with procedures—but one payer has cracked down on sending you payment for these services.

Background: Modifier 25 (Significant, separately identifiable evaluation and management service by the same physician or other qualified health care professional on the same day of the procedure or other service) typically allows you to separately bill for an E/M service performed at the same time as another procedure or service, as long as the E/M is significant and separately identifiable and the same physician performs both services on the same date.

Unfortunately, not every payer accepts the modifier at face value. Last week, insurer Tufts Health Plan posted on its website, “Effective for dates of service on or after July 1, 2014, Tufts Health Plan will not compensate for evaluation and management services billed with modifier 25 on the same day as a procedure with a 0-day, 10-day or 90-day post-operative period if the member has been seen by the same provider in the last eight weeks for the same condition. Refer to the AMA’s CPT® Coding Manual for a description of appropriate use of modifier 25.” 

Interpretation: The policy appears to apply to any situation involving a procedure with the stated global periods and an E/M service if the second visit involves the same complaint as a previous visit within the last two months. A separate and distinct E/M visit with a different diagnosis, however, should still be payable with modifier 25.

Remember edits: Don’t forget that Correct Coding Initiative (CCI) edits bundled many minor procedures into established E/M services in 2013, so it’s much more difficult to justify billing an E/M and a minor procedure.  

Prior to the second quarter of 2013, the only reason to need a 25 was the definition of the minor procedure and the fact that it included a small E/M service inherent to the procedure. As of the second quarter of 2013, CCI added a further burden of separateness by bundling the established E/M with endoscopic procedures and other minor procedures like 69210 (Removal impacted cerumen requiring instrumentation, unilateral). This does not apply to new patient, ED and xxx global procedure services with E/M codes. They still just have the small E/M service inherent to the code built-in, but are not bundled with the E/M codes. 

Keep in mind that you should use the 25 modifier only when it is correct, when it applies based on the CCI bundling rules. Overuse of the 25 modifier is a red flag for audit, so you want to have documentation to back up the separate and distinct E/M work whenever you report it.

This Medicaid Payer Tweaks Its -25 Policy

Tufts isn’t the only insurer that has changed its modifier 25 policy recently. Arkansas Medicaid changed its rules in May to reflect how to appropriately report a sick and well visit on the same date.

“Due to a change in CMS NCCI auditing, Arkansas Medicaid is no longer able to process both a sick visit and EPSDT/ARKids-First B preventative screening when performed on the same date of service without the appropriate NCCI modifier (Modifier 25). Modifier 25 must be indicated in the first position of the second billed service. This NCCI change surpasses the Medicaid policy to not bill modifiers on a sick visit when performed on the same date of service as an EPSDT screening/ARKids-First B preventative screening.”

If you’ve been reporting sick and well visits to Arkansas Medicaid without modifier 25, you can resubmit your denied claims now to get reimbursed.

Resource: To read the Tufts Health Plan announcement on modifier 25, visit www.tuftshealthplan.com/providers/provider.php?sec=news&content=modifier_25. To read the Arkansas Medicaid announcement, visit www.medicaid.state.ar.us/InternetSolution/Provider/newprov.aspx.