Wiki Modifier 25

[sameerm]

Has something changed in 2022 as regards coding a follow up visit ( eg 99213) and preventive visit ( eg 99396) together on the same day , using Modifier 25 ? I used to be able to do this all the time in non medicare patients but my EMR is flagging it starting in 2022 as Modifier 25 is not a valid modifier for either 99213 or 99396 ? Can anyone clarify ?

 

[amyjph]

What is the edit text? Some payers require a totally separate claim for the office visit if you are billing an "acute" E/M visit on the same date as a preventive. There could be other reasons it is stopping, maybe an update to the EMR system for 2022 but the edit text is not the correct reason? Is it a warning just stopping to make sure there is enough to support a separate E/M on the same day? Is it just one specific payer they are stopping for? There's lots of variables as to why the EMR is stopping it.

 

[scubakaren54@yahoo.com]

I am having the same problem and it is with different payers. If I remove it then when I validate the codes it says I need one. Do we go ahead and put the claim through?

 

[sameerm]

What is the edit text? Some payers require a totally separate claim for the office visit if you are billing an "acute" E/M visit on the same date as a preventive. There could be other reasons it is stopping, maybe an update to the EMR system for 2022 but the edit text is not the correct reason? Is it a warning just stopping to make sure there is enough to support a separate E/M on the same day? Is it just one specific payer they are stopping for? There's lots of variables as to why the EMR is stopping it.

Thanks very much for taking the time to reply.
Last year I was able to do preventive and follow up visit on the same day ( not for medicare) and bill with modifier 25 . Dont know what happened with the new year and why is my EMR ( eCW by the way) flagging that modifier 25 is not appropriate for code 99213 as well as for code 99396. I was able to ignore the message and send the clain- now have to wait to see what the Insurance says. I will also contact EMR to see if anything changed at their end. I was wondering if something changed as regards CMS rules for modifier 25 .
I will update the post to relate what happens.
Thank you again for taking the time.

 

[amyjph]

Nothing changed that I know of as far as the NCCI CMS modifier 25 definition. https://www.cms.gov/files/document/chapter1generalcorrectcodingpoliciesfinal11.pdf
Revision Date (Medicare): 1/1/2022
b) Modifier 25: The “CPT Manual” defines modifier 25 as a “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.” Modifier 25 may be appended to an evaluation and management (E&M) CPT code to indicate that the E&M service is significant and separately identifiable from other services reported on the same date of service. The E&M service may be related to the same or different diagnosis as the other procedure(s). Modifier 25 may be appended to E&M services reported with minor surgical procedures (with global periods of 000 or 010 days) or procedures not covered by Global Surgery Rules (with a global indicator of XXX). Since minor surgical procedures and XXX procedures include preprocedure, intra-procedure, and post-procedure work inherent in the procedure, the provider/supplier shall not report an E&M service for this work. Furthermore, Medicare Global Surgery Rules prevent the reporting of a separate E&M service for the work associated with the decision to perform a minor surgical procedure regardless of whether the patient is a new or established patient.

I am guessing it's either payer policy changes or a "warning edit" to make sure the use of 25 is justified before releasing. I don't have experience with eCW. Usually when EMRs update there are release notes to explain what the changes were to the edits or you should be able to find out via a lead, supervisor or manager what the updates are. Normally the 25 would go on the E/M office visit code not the preventive code.

Here's the AAPC webinar for 2022 CPT updates: https://www.aapc.com/medical-coding-education/webinars/2022-cpt-coding-updates

 

[tori.a]

Nothing changed that I know of as far as the NCCI CMS modifier 25 definition. https://www.cms.gov/files/document/chapter1generalcorrectcodingpoliciesfinal11.pdf
Revision Date (Medicare): 1/1/2022
b) Modifier 25: The “CPT Manual” defines modifier 25 as a “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.” Modifier 25 may be appended to an evaluation and management (E&M) CPT code to indicate that the E&M service is significant and separately identifiable from other services reported on the same date of service. The E&M service may be related to the same or different diagnosis as the other procedure(s). Modifier 25 may be appended to E&M services reported with minor surgical procedures (with global periods of 000 or 010 days) or procedures not covered by Global Surgery Rules (with a global indicator of XXX). Since minor surgical procedures and XXX procedures include preprocedure, intra-procedure, and post-procedure work inherent in the procedure, the provider/supplier shall not report an E&M service for this work. Furthermore, Medicare Global Surgery Rules prevent the reporting of a separate E&M service for the work associated with the decision to perform a minor surgical procedure regardless of whether the patient is a new or established patient.

I am guessing it's either payer policy changes or a "warning edit" to make sure the use of 25 is justified before releasing. I don't have experience with eCW. Usually when EMRs update there are release notes to explain what the changes were to the edits or you should be able to find out via a lead, supervisor or manager what the updates are. Normally the 25 would go on the E/M office visit code not the preventive code.

Here's the AAPC webinar for 2022 CPT updates: https://www.aapc.com/medical-coding-education/webinars/2022-cpt-coding-updates

My question regarding this definition of modifier 25 is on page 15 where it states "The decision to perform a minor surgical procedure is included in the payment for the minor surgical procedure and shall 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." We are being told that the definition did change to include the word unrelated and that the E/M must be completely unrelated (not only separately identifiable and above and beyond what's included in the procedure) to the procedure in order to bill for an E/M on the same day.