Wiki Modifier 25 Changes?

tori.a

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As of 1/1/2022 the NCCI updated its definition of modifier 25 to specify that the E/M service must not only be separately identifiable and above and beyond what's included in the procedure, but also "unrelated." Our urologists are now being told they cannot bill a hospital consult, for example, if they also insert a stent or perform a ureteroscopy same day. This seems ludicrous. Any word on this? The word "unrelated" is specified on page 15. We are being told that Noridian is performing nationwide audits regarding modifier 25 and E/M services required to be completely "unrelated."

Page 15 states "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 performed on the same date of service as a 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 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."

The usual definition of modifier 25 is then posted on page 17, adding to the confusion. I really need clarification on this because otherwise our doctors will have to see the patient for an E/M and then schedule all minor procedures rather than working efficiently and performing them same day in order to get paid fairly for their work.

 

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This is not a change in NCCI - that wording has been there for quite some time. It's not part of the definition of the modifier - it's guidance specific to minor surgical procedures and is supported by the CMS policy on the global surgical package. So yes, for surgical procedures with a 0- or 10-day global period, the E&M must be 'unrelated to the decision to perform the minor surgical procedure'. The E/M service doesn't have to be 'completely' unrelated to the procedure, it's just that the component of the E/M that involves the decision to perform the procedure can't be counted toward the E/M since it's a component of the procedure's global package. The physician can still bill for E/M services involving, for example, the treatment of the underlying condition, which might involve the same diagnosis.

The Global Surgery Booklet goes into a little more detail here, but as you can see from this publication from 2018, this language regarding the use of modifier 25 with minor procedures has been in effect prior to 2022: https://www.cms.gov/Outreach-and-Ed...oducts/Downloads/GloballSurgery-ICN907166.pdf
 
Thanks for the reply! We're being told that Noridian is conducting a nationwide audit of the use of modifier 25 and that the only criteria they provided was "unrelated" so it has caused quite a stir. But what you stated there, "The E/M service doesn't have to be 'completely' unrelated to the procedure, it's just that the component of the E/M that involves the decision to perform the procedure can't be counted toward the E/M since it's a component of the procedure's global package. The physician can still bill for E/M services involving, for example, the treatment of the underlying condition, which might involve the same diagnosis." really clears it up.
 
I have a follow up question to this. An example, really. What would you say to my example of a hospital based new patient evaluation with the decision to perform a ureteroscopy on the same day due to intractable pain? What would need to be documented in order to be paid for the E/M in addition to the ureteroscopy (no global). I think it is unreasonable that we do a full assessment of a patient in the hospital, but are penalized by not being paid for taking them promptly to the OR rather than waiting until the next day or several days later to address their problem.
 
I have a follow up question to this. An example, really. What would you say to my example of a hospital based new patient evaluation with the decision to perform a ureteroscopy on the same day due to intractable pain? What would need to be documented in order to be paid for the E/M in addition to the ureteroscopy (no global). I think it is unreasonable that we do a full assessment of a patient in the hospital, but are penalized by not being paid for taking them promptly to the OR rather than waiting until the next day or several days later to address their problem.
I can give you my own thoughts on this, but they may or may not line up with how the auditors at Noridian are going to be approaching the question. As I see it, the purpose of the rule as state in the global surgery policy is that for minor problems that can be immediately treated with a surgical procedure, the value assigned to the procedure code has been calculated to already include that initial evaluation work. So this would include something like an abscess, for example, where the incision and drainage payment would include the surgeon's work in looking at the abscess, confirming the diagnosis and checking the relevant patient history, performing the procedure, and providing post-op instructions and/or prescriptions. A separate E/M wouldn't be warranted if that's all that happened. But if the patient has some kind of comorbidity or risk factor that required significant extra work on the part of the surgeon, or some other issue that needed to be investigated before the procedure could be performed, then that could warrant a modifier 25.

In the case of a hospitalized patient, I would think that if a patient were sick enough to be admitted, then in most cases there's more going on medically that can be dealt with via a minor surgical procedure, but that would need to be reflected in documentation. So if the E/M reflects that the specialist is managing those issues in conjunction with the rest of the patient's medical team, and the procedure is just one part of a larger treatment, then you would have an argument for the modifier 25. However, if the documentation reflects that ED doctors and/or hospitalists are really the ones managing the patient, and your specialist is just coming in specifically for this one procedure and isn't going to be involved beyond just doing the procedure and the peri-operative work related to it, then it's going to be harder to justify the modifier.

This may end up being a tough fight with your payer's auditors, who likely have a financial incentive to take a stricter interpretation of the guidelines. I'd suggest starting by doing your own review of some of your providers' notes and putting yourself in the auditors position and trying to get an idea of what you're up against. If they start denying some of your E/M visits but allowing others, then you might be able to start to get a sense for what details they're looking for and are willing to accept in order to allow the modifier, and then you can use that information to educate your providers about how they can improve their documentation in order to prevent denials. If you find they're being completely unreasonable and costing your practice considerable amounts, then you might consider escalating the issue, perhaps through your providers' professional association or even by contacting an elected official.

I'd just add too that I would discourage talk about providers being 'penalized' for doing an E/M on the same date as a procedure - that's not what's happening here, and the providers need to understand this. As I mentioned above, the surgical procedure is valued to already include that work. If your providers have been in the habit of just adding an E/M with modifier 25 to every minor procedure without consideration for this guidance, then they've probably actually been overpaid a lot in the past. In addition, providers should absolutely not make medical treatment decisions based on this payer policy. The suggestion that providers might somehow change their practices and schedule patients for procedures on a later date in order to evade this policy and get better reimbursement should not even be under discussion.

Hope this helps some and hope your audits will go well.
 
I'd just add too that I would discourage talk about providers being 'penalized' for doing an E/M on the same date as a procedure - that's not what's happening here, and the providers need to understand this. As I mentioned above, the surgical procedure is valued to already include that work. If your providers have been in the habit of just adding an E/M with modifier 25 to every minor procedure without consideration for this guidance, then they've probably actually been overpaid a lot in the past. In addition, providers should absolutely not make medical treatment decisions based on this payer policy. The suggestion that providers might somehow change their practices and schedule patients for procedures on a later date in order to evade this policy and get better reimbursement should not even be under discussion.
100%
 
Hello everyone, I am new to pro-fee coding on the general surgery specialty, and I am looking for some answer.
Hope one of you can help me with the scenario below.

Patient is under 90-day global period - post Open abdominal surgery,
Patient came back to ED with abdominal pain and our surgeon was called for Inpatient consultation.
He suspects abdominal wall abscess and plans for OR for I&D with Abdominal wall debridement (say for example, this was on 12.25.22 - subsequent visit day)

Patient was seen before the procedure on 12.26.22(visit note has supporting elements for level 2 follow-up) and had the I&D plus debridement done.

My question is: Can we bill this E/M visit separately?
As subsequent visit 99232 - 24, 25 (for 12.26.22) when billing the minor procedure (which has no global day period)?

TIA
 
Last edited:
Hello everyone, I am new to pro-fee coding on the general surgery specialty, and I am looking for some answer.
Hope one of you can help me with the scenario below.

Patient is under 90-day global period - post Open abdominal surgery,
Patient came back to ED with abdominal pain and our surgeon was called for Inpatient consultation.
He suspects abdominal wall abscess and plans for OR for I&D with Abdominal wall debridement (say for example, this was on 12.25.22 - subsequent visit day)

Patient was seen before the procedure on 12.26.22(visit note has supporting elements for level 2 follow-up) and had the I&D plus debridement done.

My question is: Can we bill this E/M visit separately?
As subsequent visit 99232 - 24, 25 (for 1.26.23) when billing the minor procedure (which has no global day period)?

TIA
It's really hard to answer this question without seeing the medical record. I cannot tell from your description if the new problem (the abdominal wall abscess) is a complication of the original procedure or is unrelated. If you're not able to tell from the rest of the record, then you'd need to query the provider.

You will need to review the encounter note from the date of the minor procedure to know whether or not the modifiers 24 and 25 are supported for E/M services unrelated both to the decision to drain the abscess and also unrelated to the previous surgery. As for the I&D procedure itself, if it's unrelated to the original surgery, then you can bill it with modifier 79, but if it's a complication then you would use modifier 78.

Hope that helps some.
 
Thank you.
You are right, I am unable to tell if it's the complication of the initial procedure. Will have to check with the provider.

So, if the visit note supports a service which is "unrelated" both to this previous day's decision to drain the abscess and to the previous surgery - I can append 24 and 25.
But, if HPI says - patient will be taken in for surgery today and has the I&D the same day, even if it has all needed E/M elements - then I cannot bill that Pre-op visit separately.

Can I consider it like this?:unsure:
 
I can give you my own thoughts on this, but they may or may not line up with how the auditors at Noridian are going to be approaching the question. As I see it, the purpose of the rule as state in the global surgery policy is that for minor problems that can be immediately treated with a surgical procedure, the value assigned to the procedure code has been calculated to already include that initial evaluation work. So this would include something like an abscess, for example, where the incision and drainage payment would include the surgeon's work in looking at the abscess, confirming the diagnosis and checking the relevant patient history, performing the procedure, and providing post-op instructions and/or prescriptions. A separate E/M wouldn't be warranted if that's all that happened. But if the patient has some kind of comorbidity or risk factor that required significant extra work on the part of the surgeon, or some other issue that needed to be investigated before the procedure could be performed, then that could warrant a modifier 25.

In the case of a hospitalized patient, I would think that if a patient were sick enough to be admitted, then in most cases there's more going on medically that can be dealt with via a minor surgical procedure, but that would need to be reflected in documentation. So if the E/M reflects that the specialist is managing those issues in conjunction with the rest of the patient's medical team, and the procedure is just one part of a larger treatment, then you would have an argument for the modifier 25. However, if the documentation reflects that ED doctors and/or hospitalists are really the ones managing the patient, and your specialist is just coming in specifically for this one procedure and isn't going to be involved beyond just doing the procedure and the peri-operative work related to it, then it's going to be harder to justify the modifier.

This may end up being a tough fight with your payer's auditors, who likely have a financial incentive to take a stricter interpretation of the guidelines. I'd suggest starting by doing your own review of some of your providers' notes and putting yourself in the auditors position and trying to get an idea of what you're up against. If they start denying some of your E/M visits but allowing others, then you might be able to start to get a sense for what details they're looking for and are willing to accept in order to allow the modifier, and then you can use that information to educate your providers about how they can improve their documentation in order to prevent denials. If you find they're being completely unreasonable and costing your practice considerable amounts, then you might consider escalating the issue, perhaps through your providers' professional association or even by contacting an elected official.

I'd just add too that I would discourage talk about providers being 'penalized' for doing an E/M on the same date as a procedure - that's not what's happening here, and the providers need to understand this. As I mentioned above, the surgical procedure is valued to already include that work. If your providers have been in the habit of just adding an E/M with modifier 25 to every minor procedure without consideration for this guidance, then they've probably actually been overpaid a lot in the past. In addition, providers should absolutely not make medical treatment decisions based on this payer policy. The suggestion that providers might somehow change their practices and schedule patients for procedures on a later date in order to evade this policy and get better reimbursement should not even be under discussion.

Hope this helps some and hope your audits will go well.
I can't thank you enough for your reply here. So detailed and helpful, I reference it often when I need a reminder. Thanks!
 
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