7-2005TUMG Compliance When and How to Use These Coding Adjectives Print the Modifiers -24 and -25 Quiz before viewing the presentation

Physicians and Staff may earn one compliance credit by viewing this slide show, completing the Modifier 24 and 25 Assessment, and faxing the assessment to the University Privacy and Contracting Office: This presentation may be viewed for compliance credit only once in a fiscal year (July 1 - June 30). To check how many compliance credits you have and to see which training sessions you have completed, contact the University Privacy and Contracting Office at Read Before Proceeding

It is the policy of TUMG to provide healthcare services that are in compliance with all state and federal laws governing its operations and consistent with the highest standards of business and professional ethics. Education for all TUMG physicians is an essential step in ensuring the ongoing success of compliance efforts.

This education is Part 9 of a 9-part series on documenting and selecting the level of service for outpatient visits. All presentations are available on the Tulane University Privacy and Contracting Office website:  Part 1: Overview of Basic Principles  Part 2: Documenting a History  Part 3: Documenting an Exam  Part 4: Documenting Medical Decision Making  Part 5: Documenting Consults  Part 6: Documenting Pre- Operative and Confirmatory Consults  Part 7: Time-Based Codes  Part 8: Linking to Resident Notes  Part 9: Modifiers 24 and 25

7-2005TUMG Compliance Focus of this presentation: To discuss Modifiers -24 and -25 When and how to use Coding tips for physicians Impact on billing

What are Modifiers?  Modifiers are two (2) digit numeric or alpha characters that are reported with a CPT code, when appropriate.  Modifiers provide Medicare and commercial payors with additional (and essential) information needed to process a claim.  Modifiers provide the means by which the physician can “flag” a service that has been altered by some special circumstance(s) without changing the basic CPT code description.

7-2005TUMG Compliance Importance of Modifiers Appropriate use of modifiers is an important part of coding for services Appropriate use of modifiers is a component of billing compliance Appropriate use of modifiers allows physicians to obtain reimbursement for services rendered that would otherwise be denied if a modifier were not attached

Order of Modifiers  The first two (2) modifiers placed on a billing sheet (encounter form) are considered “critical modifiers” and will affect reimbursement for services.

Global Periods  Global periods refer to a set number of follow-up days that are included with each procedure performed  Typical global periods are 0, 10, or 90 days after the procedure 0 –10 – 90

Zero Day Global Periods  Evaluation & Management (E/M) services provided the day before or after the procedure(s) with a zero global period. Examples: Bronchoscopy EGD Removal of impacted cerumen (one or both ears)

Ten (10) Day Global Period Minor Surgical Procedures  All services (including complications) related to the procedures(s) cannot be billed separately for 10 days after the procedures.  Examples: Excision of benign lesion, trunk, arms, legs (lesion diameter 0.5 cm or less) PE tubes under local or topical anesthesia Debridement, skin, SQ tissue and muscle

Ninety (90) Day Global Period Major Surgical Procedures  All services (including complications) related to the procedures(s) cannot be billed separately for one day prior to the procedure(s) and 90 days after the procedure(s).  Examples:  Cataracts  Fem-Pop Bypass  Mitral Valve Replacement

7-2005TUMG Compliance Unrelated Evaluation and Management service by the same physician during the post-op period

When to Use Modifier –24  When a physician performs an E/M service on a patient in the post-op period for a reason(s) that is unrelated to the original procedure. By adding the modifier –24 to the appropriate E/M code, the E/M service may be billed.

Using Modifier -24 Correctly  CMS approved codes for use with -24 modifier are: (Ophthalmology Codes) (E/M)  Append -24 to the E/M code for an unrelated service, for either major or minor surgical procedures  A physician who is responsible for postoperative care (i.e, one who has reported modifier -55 – postoperative management only) may also use -24 to report any unrelated visits Source: Ingenix Coding Lab: Understanding Modifiers,

Incorrect Use of Modifier -24  Reporting the modifier with subsequent hospital care codes ( ). These services performed by the surgeon during the same hospitalization as the surgery are normally related to the surgery.  Separate payment for such visits is not allowed even when billed with the -24 modifier unless a different diagnosis is reported with the E/M service, identifying the services as unrelated to the original procedure. Source: Ingenix Coding Lab: Understanding Modifiers, page 11 copyright: Ingenix Inc 2003

Coding Tips  Append modifier -24 to an E/M service performed in the postoperative period that is unrelated to the original procedure.  NOT appending the modifier may result in a claim denial  Subsequent hospital care and critical care services during the same hospitalization are considered related to the original procedure.  It is important to understand the definition of the postoperative period and global surgical package

What Payors Recognize Modifier –24?  Not all payors recognize Modifier -24  The following payors do recognize Modifier -24 and will reimburse for those E/M services that have the modifier attached to the E/M code  Medicare  Champus  Blue Cross  United Health Care

Example - Modifier -24  A patient presents to the surgeon’s office for a post-op visit following a cholecystectomy (CPT 47600). She is 35 days postsurgery. During the visit the patient expresses concern about a mole on her neck.  The surgeon performs a problem-focused history and an expanded problem-focused physical exam. The medical decision making is of low complexity. The surgeon will perform a biopsy in three days. For E/M Service, submit CPT code The diagnosis code should describe the mole, and therefore identify the patient’s condition as unrelated to the cholecystectomy.

7-2005TUMG Compliance Significant, separately identifiable Evaluation and Management (E/M) service by the same physician the same day of a procedure

When to Use Modifier –25  A physician performs an E/M service on a patient on the same day that a procedure is performed AND the E/M service is for a condition unrelated to the procedure. By adding the modifier –25 to the appropriate E/M code, the E/M service may be billed. NOTE: This modifier is NOT used to report an E/M service that resulted in a decision to perform surgery (use modifier -57)

Using Modifier -25 Correctly  Use -25 when the E/M service is separate from that required for the procedure AND a clearly documented, distinct and significantly identifiable service was performed.  The E/M service must have all the required key elements well documented.  Use modifier -25 on an E/M service performed during the same session as a preventive care visit when a significant, separately identifiable E/M service is rendered in addition to the preventive care. The ICD-9 (diagnosis) code should identify the service as non-preventive. Source: Ingenix Coding Lab: Understanding Modifiers, page 14 copyright: Ingenix Inc 2003

Incorrect Use of Modifier 25  Attaching -25 to report an E/M service that resulted in the the decision to perform major surgery (modifier -57)  Using -25 on an E/M service performed on a different day than a procedure.  Using -25 on a surgical code ( )  Billing an E/M service with -25 when patient’s trip to the office was strictly for a scheduled minor procedure. (No significant, separately identifiable E/M service performed) Source: Ingenix Coding Lab: Understanding Modifiers, page 114copyright: Ingenix Inc 2003

What Payors Recognize Modifier –25?  Not all payors recognize Modifier -25  The following payors do recognize Modifier -25 and will reimburse for those E/M services that have the modifier attached to the E/M code  Medicare  Champus  Blue Cross  United Health Care  Aetna

LA Medicaid does not recognize Modifier –25  Medicaid does not reimburse for an E/M code and a procedure on the same day. Medicaid rules state that the visit (E/M service) cannot be billed.  The IDX Claims Manager Edits will hold any charges where an E/M and a procedure were billed on the same day. The visit must be deleted before the charge is dropped.

 Although OIG says in its 2004 Work Plan that "a provider should not bill E/M codes on the same day as a procedure or other service unless the E/M service is unrelated", CMS officials maintain that related services may be billed as long as they are "significant" and "separately identifiable," confirming a 10-year old policy to that effect. OIG officials confirmed CMS's view. CMS wrote that "a documented, separately identifiable, related service is to be paid for. We would define related as being caused or prompted by the same symptoms or conditions." Nevertheless, it is smart to assume the carrier will ask for documentation that the two services were separate and each was medically necessary. In the April 5th 2004 edition of the Medicare Compliance Alert, this statement was made

Coding Tips  Medicare will allow separate payment for two office visits provided by the same physician on the same day when each visit is rendered for an unrelated problem. Both visits must be medically necessary. Modifier -25 must be appended to the second visit. This circumstance is considered a rare occurrence.  Third-party payors vary in their recognition and reimbursement of E/M visits billed with this modifier.

7-2005TUMG Compliance Compliance Alert! The OIG (Office of the Inspector General) Work Plans have more than once identified the use of Modifier -25 as an area of focus for program review. When an individual or group has been identified, a review of claims and supporting documentation may occur for subsequent charges with the -25 modifier attached. OIG

Should these modifiers be used as routine practice even though some payors may not recognize them?  Many commercial payors follow Medicare billing guidelines. With the exception of LA Medicaid, it is recommended that physicians attach the –24 and –25 modifiers when appropriate

Should these modifiers be used as routine practice even though some payors may not recognize them? However, a word of Modifiers -24 and -25 SHOULD NOT be appended to all E/M services as a ROUTINE PRACTICE unless all requirements for use of the modifier(s) has been met. One of the reasons the OIG is looking into Modifier -25 is because initial investigation shows that many physicians do not document separate and identifiable E/M Services.

7-2005TUMG Compliance Modifier –25 Example 1 March 1: Patient returns to the Orthopaedic Clinic for scheduled Synvisc injection. Patient also complains of a sore wrist that began two days ago. E/M Code: – Diagnosis: sprained wrist Also bill for Synvisc injection. Separate, unrelated E/M service

7-2005TUMG Compliance When using Modifier –25, make sure to append the modifier to the E/M code, not to the procedure code.

7-2005TUMG Compliance Modifier –25 Example 2 February 10: ENT clinic consultation for shortness of breath, hoarseness and difficulty swallowing. During the consult a flex laryngoscopy was performed; laryngeal mass found. E/M Code: CPT Code: flex laryngoscopy Physician can bill for laryngoscopy, even though it is related to the E/M visit, because procedure was not anticipated

 The separately identifiable E/M service need not be different from the indications for doing the procedure. The E/M service may be caused or prompted by the same symptoms or conditions for which the procedure and /or service was provided. Different diagnoses are not required for reporting the procedure and E/M code.

7-2005TUMG Compliance Modifier –25 Example 3 Jan 2: Established patient is seen in the Ortho clinic for a knee aspiration. The patient comes to the clinic on a regular basis for knee aspiration E/M Code: None CPT Code: aspiration of knee joint

 NOTE: If an established patient presents for a procedure that has already been scheduled or previously decided upon, an additional E/M code with a modifier –25 should NOT be billed.

7-2005TUMG Compliance Modifier –25 Example 4 The physician examines a new patient for upper respiratory infection. During the examination the patient communicates to the physician that the hearing in his left ear is not clear. Upon examination, the physician notes a large amount of impacted cerumen. The physician removes the cerumen. E/M Code: Diagnosis: URI CPT Code: Diagnosis: Impacted Cerumen

 NOTE: For NEW PATIENTS, a physician MAY bill an E/M code and a visit on the same day AND the –25 modifier is not required.

Documentation is Essential  The medical record should clearly support the E/M service and the procedure provided by the physician.  Appropriate use of Modifiers –24 and –25 help to ensure that physicians receive payment for services rendered.  Without the modifiers, the E/M service will be denied.

Know who to contact: TUMG Business Services Compliance Reporting Hotline:

To Earn Compliance Credit: Complete and Sign the “Modifiers -24 & -25” Quiz Fax to: