Definition of "significant" for modifier 25

CatchTheWind

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What makes an E/M "significant" enough to warrants a claim with modifier 25 the same day as a minor procedure?

Humana has informed us that they will only pay an E/M with modifier 25 if the problem was significant enough to require a prescription, lab order, surgery recommendation, or something like that. If it only requires counseling or OTC medication, it is not "significant" enough to bill a separate E/M.

Example: Pt came in for evaluation of a rash, and the provider examined the area and recommended an OTC cream. The provider happened to notice an unrelated suspicious lesion and performed a biopsy. So we billed 11100 for the lesion and 99212-25 for the rash. Humana denied the 99212-25 stating that the rash was not a "significant" enough problem to bill separately because the recommendation was only for OTC medication.

Is this appropriate?
 

Pathos

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That sounds like a payer policy only. I've never seen a Modifier 25 requirement like that. As long as the problem is medically necessary, and significant, separately enough then I don't understand why your payer would deny the claim.

According to my local MAC:

"Indicates on day of a procedure or other service identified patient's condition required a significant, separately identifiable E/M service above and beyond other service provided or beyond usual pre-operative and post-operative care associated with procedure that was performed
To bill for an E/M service, must have a history, exam and medical decision making (HEM). All procedures include some service related to patient evaluation and management. A separate E/M should include its own HEM. Physician must determine whether problem is significant enough to require additional work to perform key components of problem oriented E/M service."

CMS adds:

"Modifier “-25” (Significant, separately identifiable E/M service by the same physician on the same day of the
procedure), indicates that the patient’s condition required a significant, separately identifiable E/M service
beyond the usual pre-operative and post-operative care associated with the procedure or service."

I would probably appeal this ruling, just make sure you have really good documentation to support your Modifier 25.

Hope that helps!
 

ellzeycoding

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Here is a variation on this question that I got asked recently. I disagreed with the physician.

Patient presented with a possible rash. He biopsied the rash (CPT 11100). He then wrote a prescription for ongoing treatment of the rash. Is an E/M billable here?

My argument is NO because the biopsy for the rash is a minor procedure and the E/M that leads to the decision to perform the biopsy is included in the minor procedure. The RX is related to the rash and isn't a separately identifiable issue or problem. After discounting the exam, history, etc. related to the biopsy, the only thing left documented is the prescription which might meet low level MDM. But not enough to justify a separately billable E/M because it's still related to the rash that was biopsied.

The physician disagreed, stating that the RX was for ongoing treatment of the rash he just biopsied and was separate.

Do you agree or disagree?
 

Pathos

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What was the purpose of the visit? If the visit was to treat the established rash problem, then this sounds like routine.

In order to even consider using Modifier 25, there has to be something else other than the routine treatment of a problem which is covered by any procedure code. All procedures include a low level E/M already, so if the provider wants to bill 9921* + 25, then there has to be something outside the routine treatment. Writing a prescription alone for routine treatment isn't "significant/separate", but should be part of the procedure code and the treatment. If a new problem came up during the visit that wasn't related to the rash/biopsy, and the provider managed this problem, then an E/M with modifier 25 would be appropriate.

To answer your question, based on your post and description I do not think an additional E/M with modifier 25 is appropriate for that visit.

Some readings:

Novitas - Modifier 25

Noridian - Modifier 25
 

ellzeycoding

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What was the purpose of the visit? If the visit was to treat the established rash problem, then this sounds like routine.

In order to even consider using Modifier 25, there has to be something else other than the routine treatment of a problem which is covered by any procedure code. All procedures include a low level E/M already, so if the provider wants to bill 9921* + 25, then there has to be something outside the routine treatment. Writing a prescription alone for routine treatment isn't "significant/separate", but should be part of the procedure code and the treatment. If a new problem came up during the visit that wasn't related to the rash/biopsy, and the provider managed this problem, then an E/M with modifier 25 would be appropriate.

To answer your question, based on your post and description I do not think an additional E/M with modifier 25 is appropriate for that visit.

Some readings:

Novitas - Modifier 25

Noridian - Modifier 25

It was an encounter for a chief complaint of rash (not an established problem). The patient presented with a new complaint of a rash. The provider took history, examined the rash-affected areas, and made the decision to biopsy the rash and confirm possible cause.. He then also wrote a prescription for medication to help treat the rash.

So is there enough separately identifiable E/M above and beyond what was needed to evaluate and make the decision to biopsy the rash? Is the fact that a prescription was written, a significantly separately identifiable E/M? I don't belief the record would have enough documentation to justify ANY level of care after discounting the E/M related to the minor procedure.

Again the script was related to the same complaint addressed with the biopsy.
 

mitchellde

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I say no. To be significant the evaluation must be over above and beyond that which is necessary to perform the procedure. in order to perform the biopsy in this case the are in questioned must be examined... a prescription by itself is not enough to qualify as significant since there is no significant exam however had the provider documented that other areas of the body were examined to determine if the rash was present in any other location, then you would have a significant evaluation to go along with the prescription to have a separately identifiable E&M.
 

tovygoldstein

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A podiatrist sees many patients for minor procedures which are denied for routine foot care (nail trimming, nail debridement, corn and callus removal). Many patients also have a diagnosis of dry skin, and the provider documents a corresponding exam and assessment/plan (apply moisturizer). Would this justify an office visit with modifier 25 in addition to the procedure code?

Thank you.
 

Pathos

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The keyword here is "routine". In order to use Modifier 25, the visit has to include something out of the ordinary that wasn't part of the E/M visit.
Why was the minor procedure denied? Perhaps the visit could be part of a regular E/M visit without any any procedures attached to it, but bundled into the E/M (for example, ear lavage is often included with a regular E/M).

Check your payer policy on this, or ask the payer provider rep as to why this was denied and could go from there. They should know or at least point you in the right direction.


Hope this is helpful.
 

Pathos

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If the procedure is not covered or not considered medically necessary, then you cannot bill the procedure and expect to get paid. The patient would have to sign a waiver BEFORE the procedure was done in order to transfer this to patient's responsibility.

A regular E/M might be your best bet here.
 
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