Modifier 25 appended to a professional claim indicates a significant, separately identifiable evaluation and management (“E/M”) service was rendered by the same physician on the same day as a minor procedure or other therapeutic service. Previously, the Office of Inspector General (“OIG”) identified 35% of claims using modifier 25 did not meet Medicare program requirements. Improper payments resulted from providers billing E/M services which were not significant, separately identifiable, and above and beyond the usual preoperative and postoperative care associated with the procedure or because the claims failed to meet basic Medicare documentation requirements. [1] In fact, the OIG is expected to issue a report later in 2023 specific to dermatology services billing with modifier 25. While utilization of modifier 25 is certainly not unique to dermatology, the OIG cites roughly 56% of dermatology claims in 2019 billed with an E/M service also included a minor surgical procedure. [2]
Despite outreach efforts by various Medicare Administrative Contractors to reduce improper payment, confusion persists. Relative to the appropriate use of modifier 25, National Government Services indicates “Through the process of medical review we have found providers frequently fail to produce documentation that is sufficient or convincing enough to support billing for both services.” [3] While supporting documentation is not required to be submitted along with the claim, the documentation in the patient’s medical record must support a separately identifiable E/M service.
Keys to Understanding
To mitigate the risk associated with misuse of modifier 25, SunStone offers focused education, highlighting the two critical aspects of Medicare global surgery rules which often help facilitate a better understanding of the concept:
Generally, E/M services on the same day as a minor surgical procedure are included in the payment for the procedure. [4] Integral to the valuation of the procedure, it’s important to note that all procedures include some service elements related to patient E/M. Documentation must be significant and separately identifiable from usual work associated with the procedure.
The decision to perform a minor procedure is included in the payment for the minor procedure and should not be separately reported as an E/M service.[5] When a non-scheduled procedure is performed, that decision-making process alone does not warrant a separate E/M service.
While Medicare stipulates the same diagnosis is permissible on the E/M and the procedure performed on the same day, to support billing a separate E/M, documentation should include unique history, physical exam and plan elements or medical decision making over and above that which is related to the procedure. [6] Ultimately, the physician must determine whether the problem is significant enough to require additional work to perform key components of a problem-oriented E/M service. Noridian Medicare Services summarizes it this way “A significant, separately identifiable E/M service is defined or substantiated by documentation that satisfies the relevant criteria for the respective E/M service to be reported.” [7]
Watch E/M Levels Under the Revised Framework!
Under the revised E/M framework medical decision making alone, or total time determine the level of E/M service. To support medical decision making, documentation must address the complexity of the problem addressed, any data ordered or reviewed, and risk of management decisions made aside from the decision for the procedure. If utilizing time, physicians must carve out distinct time for the separate E/M service that specifically omits time spent rendering the procedure. [8] It’s also important to note, a time-based E/M billed separately must be medically necessary and be distinct from discussion time spent counseling on risks and benefits as well as procedure outcome.
To assist providers navigate the complexities surrounding modifier 25, SunStone is offering a free 30-minute Webinar on April 19th at 12:00 noon Eastern Daylight Time. We will provide more details surrounding the proper use of modifier 25 and review clinical scenarios which draw from redacted documentation examples. To register for the session, please email the following:
SunStone Consulting offers comprehensive services geared to help hospitals and health systems evaluate and navigate the ever-changing regulatory environment. If you have any questions, please contact:
Vonda Moon, Senior Principal at vondamoon@sunstoneconsulting.com
Joli Fitzgibbons, Director at jolifitzgibbons@sunstoneconsulting.com
Cathy Archuleta, Senior Manager at cathyarchuleta@sunstoneconsulting.com
[1] https://oig.hhs.gov/oei/reports/oei-07-03-00470.pdf
[2] https://www.oig.hhs.gov/reports-and-publications/workplan/summary/wp-summary-0000577.asp
[3] https://www.ngsmedicare.com/web/ngs/modifiers?selectedArticleId=1636016&lob=96664&state=97178®ion=93623
[4] https://www.cms.gov/files/document/medicare-ncci-policy-manual-2023-chapter-11.pdf
[5] https://www.cms.gov/files/document/medicare-ncci-policy-manual-2023-chapter-11.pdf
[6] https://www.cms.gov/regulations-and-guidance/guidance/manuals/downloads/clm104c12.pdf
[7] https://med.noridianmedicare.com/web/jeb/topics/modifiers/25
[8] https://www.ama-assn.org/practice-management/cpt/cpt-evaluation-and-management