Wiki Modifier -25 Misuse

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ebonih9@gmail.com

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Hello All, I current complete coding audits for an insurance plan and I run across providers that append modifier -25 to every E/M code even on claims where there isn't a CCI edit and when there is only one E/M code on the claim. I have been denying these as incorrect use of a modifier. Can you please share your thoughts on if you believe if a modifier is appended unnecessarily that it should be denied.
 
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All modifiers should be used appropriately. Specifically, -25 is a misunderstood, overused, and abused modifier. Whether or not a carrier denies an unnecessary -25 would be up to the carrier policy.
Sometimes, -25 is appended to an E&M when there are not NCCI edits between the procedure and E&M as some carriers have bundling edits beyond NCCI.
For example let's say a provider performs 99213 and 51798 (no NCCI edit). However, Payor2 has an internal policy to bundle these codes. The records support the procedure and E&M are for different reasons and both codes are supported.
So, a coder may frequently need to bill 99213-25, 51798 and could get in the habit of billing that way for all payors. It can get very confusing for coders when carriers create their own policies/edits above and beyond NCCI and sometimes refuse to even share those policies/edits with the providers.
In MY opinion, if an E&M is the ONLY service, denying due to -25 would seem fair. If there is another procedure, but your specific employer does not bundle, I do not think the claim should be denied. Your employer likely has a different opinion. Usually a payor will build these type of rules into their claims processing system.
An E&M and bundled procedure billed with an UNSUPPORTED -25 (after review of records) should be denied.
 
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It depends on the internal policy and edits of the plan you work for. Christine has good advice above. When talking about the provider side, they would probably say does it "hurt" anything to "accidentally" apply a 25 modifier when nothing else was billed on that claim/date that would require it? Probably not. However, from a payer and auditing/coding standpoint, it is a red flag that the provider is just automatically appending a 25 to everything to bypass any and all edits. In my view, it should be denied. It is being appended incorrectly when NCCI does not call for it. If there is nothing else performed or billed on that date which would require a 25 they are using it incorrectly and that is an error. These providers that have use of the 25 modifier that is not in line with other providers in the geographic area and specialty are red flags. Same with 59.
 
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amyjph said:
It depends on the internal policy and edits of the plan you work for. Christine has good advice above. When talking about the provider side, they would probably say does it "hurt" anything to "accidentally" apply a 25 modifier when nothing else was billed on that claim/date that would require it? Probably not. However, from a payer and auditing/coding standpoint, it is a red flag that the provider is just automatically appending a 25 to everything to bypass any and all edits. In my view, it should be denied. It is being appended incorrectly when NCCI does not call for it. If there is nothing else performed or billed on that date which would require a 25 they are using it incorrectly and that is an error. These providers that have use of the 25 modifier that is not in line with other providers in the geographic area and specialty are red flags. Same with 59.
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I completely agree with your response and thank you for answering. I audit for the FWA (Fraud, Waste and Abuse) department and I am trained to identify and eradicate fraud and abuse. We audit for accuracy and compliance, and AMA sets rules and CMS set-up NCCI edits to assist coders with accurately coding. I feel that it is abusive to add modifiers inappropriately so that it ill not hit an edit. That means you are purposely trying to defraud the plan! Thank you again
 
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amyjph said:
It depends on the internal policy and edits of the plan you work for. Christine has good advice above. When talking about the provider side, they would probably say does it "hurt" anything to "accidentally" apply a 25 modifier when nothing else was billed on that claim/date that would require it? Probably not. However, from a payer and auditing/coding standpoint, it is a red flag that the provider is just automatically appending a 25 to everything to bypass any and all edits. In my view, it should be denied. It is being appended incorrectly when NCCI does not call for it. If there is nothing else performed or billed on that date which would require a 25 they are using it incorrectly and that is an error. These providers that have use of the 25 modifier that is not in line with other providers in the geographic area and specialty are red flags. Same with 59.
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Thank you for your reply, I appreciate your feedback and point of view.
 
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