1 Use of Modifier 25 – 2017 Medicare Physician Fee Schedule Proposed Rule July 12, 2016 The Centers for Medicare & Medicaid Services (CMS) and the Office of Inspector General (OIG) have reviewed the use of Modifier 25 to unbundle payments for evaluation and management (E/M) services when a procedure is performed. In the 2017 Medicare Physician Fee Schedule Proposed Rule¹, CMS has identified 83 target codes for review. Modifier 25 should only be used when services are provided beyond those considered to be part of the procedure performed. The over use of Modifier 25 was noted by the OIG in 2005². In the 2005 report the OIG found that 35% of the claims using Modifier 25 did not meet the billing guidelines, resulting in improper payments. The specific listing of the 83 target codes in the 2017 Proposed Rule could mean increased auditing of the use of Modifier 25. The codes targeted are listed below in Table 7 from the proposed rule. TABLE 7: 0-day Global Services that are Typically Billed with an Evaluation and Management (E/M) Service with Modifier 25 HCPCS Long Descriptor 11000 Removal of inflamed or infected skin, up to 10% of body surface 11100 Biopsy of single growth of skin or tissue 11300 Shaving of 0.5 centimeters or less skin growth of the trunk, arms, or legs 11301 Shaving of 0.6 centimeters to 1.0 centimeters skin growth of the trunk, arms, or legs 11302 Shaving of 1.1 to 2.0 centimeters skin growth of the trunk, arms, or legs 11305 Shaving of 0.5 centimeters or less skin growth of scalp, neck, hands, feet, or genitals 11306 Shaving of 0.6 centimeters to 1.0 centimeters skin growth of scalp, neck, hands, feet, or genitals 11307 Shaving of 1.1 to 2.0 centimeters skin growth of scalp, neck, hands, feet, or genitals 11310 Shaving of 0.5 centimeters or less skin growth of face, ears, eyelids, nose, lips, or mouth 2 11311 Shaving of 0.6 centimeters to 1.0 centimeters skin growth of face, ears, eyelids, nose, lips or mouth 11312 Shaving of 1.1 to 2.0 centimeters skin growth of face, ears, eyelids, nose, lips, or mouth 11740 Removal of blood accumulation between nail and nail bed 11755 Biopsy of finger or toe nail 11900 Injection of up to 7 skin growths 11901 Injection of more than 7 skin growths 12001 Repair of wound (2.5 centimeters or less) of the scalp, neck, underarms, trunk, arms or legs 12002 Repair of wound (2.6 to 7.5 centimeters) of the scalp, neck, underarms, genitals, trunk, arms or legs 12004 Repair of wound (7.6 to 12.5 centimeters) of the scalp, neck, underarms, genitals, trunk, arms or legs 12011 Repair of wound (2.5 centimeters or less) of the face, ears, eyelids, nose, lips, or mucous membranes 12013 Repair of wound (2.6 to 5.0 centimeters) of the face, ears, eyelids, nose, lips, or mucous membranes 17250 Application of chemical agent to excessive wound tissue 20526 Injection of carpal tunnel 20550 Injections of tendon sheath, ligament, or muscle membrane 20551 Injections of tendon attachment to bone 20552 Injections of trigger points in 1 or 2 muscles 20553 Injections of trigger points in 3 or more muscles 20600 Aspiration or injection of small joint or joint capsule 3 20604 Arthrocentesis, aspiration or injection, small joint or bursa (eg, fingers, toes); with ultrasound guidance, with permanent recording and reporting 20605 Aspiration or injection of medium joint or joint capsule 20606 Arthrocentesis, aspiration or injection, intermediate joint or bursa (eg, temporomandibular, acromioclavicular, wrist, elbow or ankle, olecranon bursa); with ultrasound guidance, with permanent recording and reporting 20610 Aspiration or injection of large joint or joint capsule 20611 Arthrocentesis, aspiration or injection, major joint or bursa (eg, shoulder, hip, knee, subacromialbursa); with ultrasound guidance, with permanent recording and reporting 20612 Aspiration or injection of cysts 29105 Application of long arm splint (shoulder to hand) 29125 Application of non-moveable, short arm splint (forearm to hand) 29515 Application of short leg splint (calf to foot) 29540 Strapping of ankle or foot 29550 Strapping of toes 30901 Simple control of nose bleed 30903 Complex control of nose bleed 31231 Diagnostic examination of nasal passages using an endoscope 31238 Control of nasal bleeding using an endoscope 31500 Emergent insertion of breathing tube into windpipe cartilage using an endoscope 31645 Aspiration of lung secretions from lung airways using an endoscope 31575 Diagnostic examination of voice box using flexible endoscope 31579 Examination to assess movement of vocal cord flaps using an endoscope from lung 4 airways using and endoscope 32551 Removal of fluid from between lung and chest cavity, open procedure 32554 Removal of fluid from chest cavity 40490 Biopsy of lip 43760 Change of stomach feeding, accessed through the skin 45300 Diagnostic examination of rectum and large bowel using an endoscope 46600 Diagnostic examination of the anus using an endoscope 51701 Insertion of temporary bladder catheter 51702 Insertion of indwelling bladder catheter 51703 Insertion of indwelling bladder catheter 56605 Biopsy of external female genitals 57150 Irrigation of vagina or application of drug to treat infection 57160 Fitting and insertion of vaginal support device 58100 Biopsy of uterine lining 64405 Injection of anesthetic agent, greater occipital nerve 64418 Injection of anesthetic agent, collar bone nerve 64455 Injections of anesthetic or steroid drug into nerve of foot 65205 Removal of foreign body in external eye, conjunctiva 65210 Removal of foreign body in external eye, conjunctiva or sclera 65222 Removal of foreign body, external eye, cornea with slit lamp examination 67515 Injection of medication or substance into membrane covering eyeball 5 67810 Biopsy of eyelid 67820 Removal of eyelashes by forceps 68200 Injection into conjunctiva 69100 Biopsy of ear 69200 Removal of foreign body from ear canal 69210 Removal of impact ear wax, one ear 69220 Removal of skin debris and drainage of mastoid cavity 92511 Examination of the nose and throat using an endoscope 92941 Insertion of stent, removal of plaque or balloon dilation of coronary vessel during heart attack, accessed through the skin 92950 Attempt to restart heart and lungs 98925 Osteopathic manipulative treatment to 1-2 body regions 98926 Osteopathic manipulative treatment to 3-4 body regions 98927 Osteopathic manipulative treatment to 5-6 body regions 98928 Osteopathic manipulative treatment to 7-8 body regions 98929 Osteopathic manipulative treatment to 9-10 body regions G0168 Wound closure utilizing tissue adhesive(s) only G0268 Removal of impacted cerumen (one or both ears) by physician on same date of service as audiologicfunction testing Palmetto GBA has published a National Correct Coding Initiative (NCCI) Tool – CPT Modifier 25.³ A summary of the guidelines for proper use of Modifier 25 are as follows: • The E/M services must be more than the usual work associated with the procedure. 6 • The documentation must support the used of the modifier. In other words, there must be a significant, separately identifiable E/M service that meets the criteria for the code assigned. • The modifier should not be used with new patient codes – they are not required, unless the service is chemotherapy, which is not considered surgical. • The diagnosis code for the E/M service does not have to be different than the surgical code, even if Modifier 25 is used. • NCCI edits must be reviewed for possible bundling. o If the code pairs are identified with 0, then the E/M service may not be billed. o If the code pairs are identified with 1, then Modifier 25 can be used if there is a separate visit, site, incision/excision, lesion, or injury and the documentation supports the E/M service as above the work necessary for the procedure. The following are three examples of the correct use of CPT Modifier from the NCCI Tool Example 1: Beneficiary medical history: date of service January 3, 2011, CPT code 20610, HCPCS modifier LT (knee joint injection, 0 global days) • On January 3, 2011, an E/M service is submitted with CPT code 99214. The patient was scheduled to receive an injection into the left knee. Due to the failure to control pain and inflammation in the left osteoarthritic knee with prior medical treatments (oral meds and joint injections), further evaluation was performed by the physician and TKR (total knee replacement) of the left knee is planned. • Outcome: Submit CPT modifier 25 with the visit for the evaluation and planned major surgery to treat the patient’s arthritis Example 2: Beneficiary medical history: date of service February 15, 2011, CPT code 20553 (trigger point injections, 0 global days) • On February 15, 2011, an E/M service is submitted with CPT code 99213. The patient was evaluated for treatment of neck pain and elevated blood pressure. The trigger point injections were administered for neck pain. New meds were prescribed to control the patient's elevated blood pressure. • Outcome: Submit CPT modifier 25 with the visit for the evaluation and treatment of the patient's elevated blood pressure 7 Example of Incorrect use of CPT Modifier 25 • On January 24, 2011, an E/M service is submitted with CPT code 99213 and CPT modifier 25. During the same patient encounter, the physician also debrides the skin and subcutaneous tissues (CPT code 11042, 0 global days). CPT 99213 was submitted to reflect the physician's time, examination and decision making related to determining the need for skin debridement. The physician's time was not significant and separately identifiable from the usual work associated with the surgery, and no other conditions were addressed during the encounter. • Outcome: Do not submit the E/M service. The E/M service is not separately reimbursable from the surgical procedure. Submit only the surgical procedure (CPT code 11042). Conclusion Because of the increased focus on the use of Modifier 25, an analysis of provider billing is suggested. If a higher than expected volume is noted by any provider, it would be necessary to conduct a targeted audit to determine if there is sufficient documentation to support the use of Modifier 25. The increased focus by CMS noted in the 2017 Physician Fee Schedule Proposed Rule should heighten awareness for all providers regarding the correct use of Modifier 25. Education concerning the correct use of Modifier 25 for providers, coders and billing staff is a good first step. Contact Information If you have any questions please contact Tom Stukes at 336.574.8065 or TStukes@wcsr.com, Sharon Clayton RN, MS, MBA, CPC at 336.728.7108 or SClayton@wcsr.com or any member of Womble Carlyle’s Healthcare Practice Group. __________________ Womble Carlyle client alerts are intended to provide general information about significant legal developments and should not be construed as legal advice regarding any specific facts and circumstances, nor should they be construed as advertisements for legal services. ¹ https://s3.amazonaws.com/public-inspection.federalregister.gov/2016-16097.pdf ² https://oig.hhs.gov/oei/reports/oei-07-03-00470.pdf ³ http://www.palmettogba.com/palmetto/webTool.nsf/vTool/mod25
Register now for your free, tailored, daily legal newsfeed service.
Questions? Please contact firstname.lastname@example.orgRegister
Use of Modifier 25 - 2017 Medicare Physician Fee Schedule Proposed Rule
To view this article you need a PDF viewer such as Adobe Reader.
Popular articles from this firm
If you would like to learn how Lexology can drive your content marketing strategy forward, please email email@example.com.