Wiki 25 Modifier

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ARCPC9491

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I need some opinions when a 3rd party biller is adding the 25 modifier to claims when the "superbill" or "fee ticket" does not have the 25 modifier identified by the provider. So, when this 3rd party has a claim with an E/M and another procedure, they are automatically adding modifier 25 without review of the notes.

I already know the answer, but I'm being shut down. I need to take your responses to take to the practice administrator, so everyone please respond!!:)
 
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well, if there was a procedure and an E/M wouldn't you need the 25 mod on the E/M? And, if the procedure "wasn't" significantly separate -then, it wouldn't/shouldn't be charged out separately (right?), and then of course - you wouldn't need a .25 on the E/M because you wouldn't be charging a procedure....

maybe I'm not reading your question correctly?
 
Basically what I'm saying is would it be appropriate for a biller (billing service) to automatically append modifier 25 to the E/M when they don't even know if the E/M is appropriately documented to begin with. They do not review the records at all. So for all they know the documentation may not even support what they are billing out. And since they are making the decision to add the modifier 25 - without reviewing the notes - wouldn't they be held liable in the event they were audited? Does that help?
 
As far as if they would be liable...I'm not sure, but I definitely understand what you are asking and NO, I wouldn't think it would be appropriate for them to add or amend anything unless they are certified coders, coding each account, in-house. Those are your charts and your coders are ultimately responsible for them, not the billers. A biller isn't a coder! Especially when, like you said, they don't even have a chart to review before they do this. Definitely a no-no!
 
I see what you're saying now... But, I think (and of course it's just my opinion),... that the 3rd party payer is "assuming" that the services were billed out accordingly, LESS a required modifier, so they add one. I suppose they're "assuming" (again) that a procedure code would NOT be billed/coded had the procedure not been provided. However, modifiers are often missed (sad but true). I guess it's much more likely that a modifier is missed rather than a procedure that wasn't actually done being billed with and E/M. Although I understand both can happen.

My guess is, whoever coded the procedure that was NEVER done could/might/should be held responsible, ...I mean really - if documentatation didn't support it, why was it billed/coded out? Where'd they come up with the code if nothing was done, nothing was verified by documentation??? The insurance company is accepting those charges as "being provided" and paying accordingly by automatically adding the modifier on the E/M because they're taking that bill at face value that those services were indeed provided and that's how they got billed/coded in the first place.

in the billing / insurance world, isn't it a "given" that when something gets billed/charged it's because that service was provided? (yes I know there's insurance fraud and such) BUT, the industry as a whole accepts those charges as "services provided" and so they pay. Sometimes they have questions, so they deny and ask for more info, but for the most part they accept the charges given, and pay accordingly...
 
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Let me give more details. I'm not saying when an insurance adds a modifier, when a biller does. A primary care physician has a superbill. Let's just say the doc circles a 99213 and a joint injection. The physician does his superbills himself, has no coders. The doc sends the superbill to their contracted biller, who is not certified in anything. The biller bills it as 99213-25 and the CPT for the joint injection -- never knowing if a 99213 was actually appropriately documented. They assume it is, and add modifier 25. The biller is determining if the service was significant and seperately identifiable -- not a coder or the physician -- without looking at the notes. Is it fair for the biller to assume to add it automatically, even when certified coders are on staff and available? The 25 modifier is often abused. What I'm being told is this "biller's practice" is when an E/M and procedure is "circled on the charge slip" they are adding 25 modifier every single time. Is this a wrong practice?
 
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Why would the provider bill for an E/M AND a Procedure, if they didn't INTEND to have the E/M paid for as a separate procedure, as denoted by a -25 modifier ?

The third-party biller is ASSUMING that you want the E/M paid for, which is why you listed it...so they added the -25, so that it would be paid...nice guys...

It is the Provider's responsibility, in my opinion, "always", to know WHAT they are BILLING, and what they are being PAID for...and that their records document this fact.

I would notify your providers of what is happening, so that your concerns are noted in your communications with them, and let them decide how to proceed. What happens next is none of your concern.

Dr G
 
25 modifier

We have ran across this a time or two here also. My boss has told all the billers that no-one adds modifiers to anything without a review of the claim/which in turn means a review of the chart. That's where I come in. I am in the billing office but I am the physician coder for our hospital. None of our billers add anything without checking first as of a year ago when I was added to the team. Then I get the claim review and ask for the office notes to see if, indeed, a modifier should or should not be added. Sometimes, there isn't even a need for an E/M to begin with and requires modification of the charges. This is where a lot of problems have happened for a lot of facilities. No modifier should be added without review. It's an assumption that should not be made.
This of course, is my opinion.
 
Most of these physicians don't even know what modifier 25 is ... so let's say they the provider gets dinged in an audit because the 25 modifier was misused resulting in overpayments because the documentation doesn't support the service? Yes, the provider is responsible for it all but wouldn't the biller get in trouble as well?
 
If the physicians do not want the billing company to add modifiers, then they need to take the initiative to educate themselves, add the modifiers to the superbills so that they can circle them themselves. They are the ones that are circling the superbill, it is their responsibility to make sure that their documentation supports what they are telling the billing company to bill out. The billing personell are doing their jobs by adding the modifiers to make sure that appropriate payment is received. If the billers didnt do this, could you imagine the lost revenue?

(I see your point but its the inevitiable with outsourcing)
 
I am a coder and biller. I code for family, Int Med and Obgyn. Some on my Docs rely on me to pick up on the OV w/Procedure. I always pull the note and make sure the document warrants the code. A pt will make an appt for shoulder pn Doc accesses and decides to do an injection so it gets the ov w/25 and proper inj procedure. If pt comes in for the shot only, then no E&M is warranted because the CC was for inj only.
 
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Biller should NOT automatically add -25

I do not think the billers should be automatically adding the -25 modifier.

As many times as I've explained to our physicians that if the reason for the visit was to have the procedure (e.g. injection or burn dressing change), then there is no separatley identifiable E/M UNLESS they are evaluating and managing something else entirely ... I have one provider who ALWAYS marks the E/M on every visit.

Our billers will put through the charge (WITHOUT the -25 modifier), just as it was marked on the superbill and then it will eventually appear on my global denial report. ARRGH!

But, as frustrating as it is, I'd rather have it this way than be sending through fraudulent claims and getting reimbursed for a "significant separately reportable" service that was neither significant nor separately reportable.

Just my two cents ...

F Tessa Bartels, CPC, CEMC
 
jegaydos said:
Why would the provider bill for an E/M AND a Procedure, if they didn't INTEND to have the E/M paid for as a separate procedure, as denoted by a -25 modifier ?

The third-party biller is ASSUMING that you want the E/M paid for, which is why you listed it...so they added the -25, so that it would be paid...nice guys...

It is the Provider's responsibility, in my opinion, "always", to know WHAT they are BILLING, and what they are being PAID for...and that their records document this fact.

I would notify your providers of what is happening, so that your concerns are noted in your communications with them, and let them decide how to proceed. What happens next is none of your concern.

Dr G
Click to expand...

I think you misunderstood what she meant by her post. The fact that the E/M may need a modifier is NOT what is in question. The fact that a biller, that has no coding experience whatsoever (as far as anyone knows anyway), is adding a modifier as common practice without having the documentation to review.
If they think that it needs a modifier appended, then they should notify the provider, who they happen to work for, let them decide whether or not to add it, and maybe let them know if they may think it is being billed improperly, and leave it up to the provider to decide how to bill their own charts. If they have useful examples or ideas to share with the provider on how they think things get paid for, etc., then great, let them share the info with the provider. But how do they know whether or not is a seperate identifiable charge? You can't bill just to get paid. If it isn't document...You Can't Bill For It.
 
It is absolutely not right for the biller to append modifier 25 without review of documentation. Actually, the biller should enter code on claim as the physician has it on super-bill without mod 25. This will definitely be denied by the 3rd party payer at that point, an appeal with medical records may be sent for review. In case of an audit the biller would definitely be in trouble. I work for a third party payer vendor and we review documentation of over 85% of claims submitted with modifier 25. There are lots of providers that understand how to use this modifier and use it appropriately, nonetheless, there are several and I mean several who abuse this same modifier.
 
Another possible solution could be for all fee tickets with E/M and procedure be routed through you before going to the billing company for "data entry". And in the meantime, education to both the billing company on the inappropriateness of changing the submitted bills and the providers on the appropriateness of adding an E/M to a procedure.
 
Thanks guys for the responses. I'm not employed for this practice or physician, I'm consulting and assessing their billing practices and functions. I wanted to get some input. I agree with not adding mod 25 unless the documentation is reviewed by someone who has coding experience, or is certified, or by the physician themselves.

However, I will present both sides of the coin and how they proceed is their decision.

Thanks a whole lot!:D
 
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