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Modifier 25 - We are updating our compliance

ahuffine

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We are updating our compliance program and we have come across some discrepancies in regards to -25 use with New Patients and minor procedure with 0 global days.

Referencing the NCCI Policy Manual for Medicare Services, E&M Services page 17 paragraph 5:

If a procedure has a global period of 000 or 010 days, it is defined as a minor surgical procedure. In general E&M services on the same date of service as the minor surgical procedure are included in the payment for the procedure. The decision to perform a minor surgical procedure is included in the payment for the minor surgical procedure and should not be reported separately as an E&M service. However, a significant and separately identifiable E&M service unrelated to the decision to perform the minor surgical procedure is separately reportable with modifier 25. The E&M service and minor surgical procedure do not require different diagnoses. If a minor surgical procedure is performed on a new patient, the same rules for reporting E&M services apply. The fact that the patient is “new” to the provider is not sufficient alone to justify reporting an E&M service on the same date of service as a minor surgical procedure. NCCI contains many, but not all, possible edits based on these principles.

MLN MM2025 updated 11/1/2012

Physicians and qualified nonphysician practitioners (NPP) should use CPT modifier -25 to designate a significant, separately identifiable E/M service provided by the same physician/qualified NPP to the same patient on the same day as another procedure or other service with a global fee period.

AAPC CPT Manual 2016

References the above MLN stating a -25 does not need to be appended on EM for any procedure with a 0 global day.


It seems the MLN conflicts with the NCCI policy re procedures that have 0 global days ie: 11100. Does anyone have any insight into this? Are you coding New E&M with this code?
 

CodingKing

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I don't see where NCCI and MLN contradict. Both discuss significant and separately identifiable E&M on same day as a minor surgical procedure. NCCI just goes in more detail stating that not all E&M services performed on the same date are considerred Significant and Separately identifiable.

AMA (I'm assuming AAPC is typo) and CMS don't always agree which is where you will see differences.
 
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ahuffine

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Thank you CodingKing for your response.

I guess what we are trying to wrap our minds around because we have some disagreement with a provider: Can we bill a new office visit with a skin biopsy (has NO global period) without a -25?
 

CodingKing

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Thank you CodingKing for your response.

I guess what we are trying to wrap our minds around because we have some disagreement with a provider: Can we bill a new office visit with a skin biopsy (has NO global period) without a -25?
NCCI overrides AMA guidelines in the CPT manual.
 

Susan

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Thank you CodingKing for your response.

I guess what we are trying to wrap our minds around because we have some disagreement with a provider: Can we bill a new office visit with a skin biopsy (has NO global period) without a -25?
This situation comes up often in my office. The best advise I could give you is to take the decision to do the biopsy out of your documentation and remove anything else in the documentation related to the biopsy; if you still have enough to bill a new visit i.e. 99201 then you are golden. Be careful on this as CodingKing is correct regarding CMS and AMA not always seeing "eye to eye".
 

CatchTheWind

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Our experience has been that the commercial payers all want modifier 25 in this situation, whereas our Medicare contractor (Florida) does not want the modifier.
 
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