Business Briefs: Use Modifier -25 Sparingly

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Both private and governmental payers have increased their scrutiny pertaining to the use and misuse of Modifier -25 over the last few years. The Current Procedural Terminology (CPT^®) manual defines Modifier -25 as a “significant, separately identifiable evaluation and management (E/M) service by the same physician on the same day of the procedure.” Therefore, the use of this modifier indicates that the patient’s condition requires a significant, separately identifiable E/M service beyond the usual preoperative and postoperative care associated with a procedure. The medical record must include documentation of the required E/M elements to justify the use of the procedure code and the selected E/M code. Although global surgical packages do not apply to wound care hospital-based outpatient departments (HOPDs), the E/M portion built into the surgical procedures does pertain to HOPDs. That is why physicians and HOPDs cannot bill an E/M code with a procedure on the same date of service, unless the E/M is for a totally unrelated or different problem than minor surgical procedures that have a 0-day global surgical period. NOTE: Most wound care-related surgical procedures performed in HOPDs by physicians have a 0-day global surgical package. Wound care providers may not have realized that both the American Medical Association (AMA) and the Centers for Medicare & Medicaid Services (CMS) describe the surgical package. However, the AMA does not include the term “global” — this may explain the confusion surrounding the coding and billing with Modifier -25. The AMA’s description of the surgical package can be found on page 66 of the 2017 CPT manual:

• E/M services subsequent to the decision for surgery on the day before or day of surgery, including the history and physical.
• Local infiltration, metacarpal/metatarsal/digital block, or topical anesthesia.
• Immediate postop care, including dictating operative notes, and talking with the family as well as other physicians or other qualified healthcare professionals.
• Writing orders.
• Evaluating the patient in the post-anesthesia recovery area.
• Typical postoperative follow-up care.

CMS describes the components of a global surgical package in the Medicare Claims Processing Manual, Chapter 12, sections 40 and 40.1 (www.cms.gov/regulations-and-guidance/guidance/manuals/downloads/clm104c12.pdf). They are:

• Preoperative visits after the decision is made to operate, beginning with the day before the day of surgery for major procedures and the day of surgery for minor procedures. NOTE: The initial evaluation for minor surgical procedures is always included in the global surgical package.
• Intraoperative services that are normally a usual and necessary part of a surgical procedure.
• Complications following surgery: All additional medical or surgical services required of the surgeon during the postoperative period of the surgery because of complications that do not require additional trips to the operating room.
• Postoperative visits during the postoperative period of the surgery that are related to recovery from the surgery.
• Postsurgical pain management by the surgeon.
• Supplies, except for those identified as “exclusions.”
• Miscellaneous services, such as dressing changes; local incisional care; removal of operative pack; removal of cutaneous sutures and staples, lines, wires, tubes, drains, casts, and splints; insertion, irrigation, and removal of urinary catheters, routine peripheral intravenous lines, nasogastric, and rectal tubes; and changes and removal of tracheostomy tubes.

CMS also describes the services that are not included in the global surgical package and that can be billed and paid for separately:

• The initial consultation or evaluation of the problem by the surgeon to determine the need for surgery. NOTE: This policy only applies to major surgical procedures and may be designated with Modifier -57. The initial evaluation is always included in the allowance for a minor surgical procedure.
• Services of other physician(s), except where the surgeon and the other physician(s) agree on the transfer of care. This agreement may be in the form of a letter or an annotation in the discharge summary, hospital record, or ambulatory surgery center record.
• Visits unrelated to the diagnosis for which the surgical procedure is performed, unless the visits occur due to complications of the surgery.
• Treatment for the underlying condition or an added course of treatment that is not part of normal recovery from surgery.
• Diagnostic tests and procedures, including diagnostic radiological procedures.
• Clearly distinct surgical procedures during the postoperative period that are not re-operations or treatment for complications. (A new postoperative period begins with the subsequent procedure.) This includes procedures done in two or more parts for which the decision to stage the procedure is made prospectively or at the time of the first procedure. 
• Treatment for postoperative complications that requires a return trip to the operating room (OR). An OR for this purpose is defined as “a place of service specifically equipped and staffed for the sole purpose of performing procedures.” The term includes a cardiac catheterization suite, a laser suite, and an endoscopy suite. It does not include a patient’s room, a minor treatment room, a recovery room, or an intensive care unit (unless the patient’s condition was so critical that there would be insufficient time for transportation to an OR).
• If a less extensive procedure fails and a more extensive procedure is required, the second procedure is payable separately.
• For certain services performed in a physician’s office, separate payment can no longer be made for a surgical tray (Code A4550). This code is now a “Status B” and is no longer a separately payable service on or after Jan. 1, 2002. However, splints and casting supplies are payable separately under the reasonable charge payment methodology.
• Immunosuppressive therapy for organ transplants.
• Critical care services (codes 99291 and 99292) unrelated to the surgery, where a seriously injured or burned patient is critically ill and requires constant attendance of the physician.

The CMS definitions of 0-, 10-, and 90–day global surgical periods will help clarify when an E/M service is separately identifiable. When reviewing the definitions, keep in mind that global surgical packages are based on the number of postop days.

• 0-day global surgical periods (includes minor procedures) do not include preoperative or postoperative days. An E/M visit on the day of the minor procedure is generally not payable as a separate service. For example, commonly used wound care CPT codes 11042, 97597, and 15275 are 0-day global surgical period procedures. Therefore, E/M services should not be separately reported when these procedures are performed. 
• 10-day global surgical periods (includes other minor procedures) do not have a preoperative period. An E/M on the day of the minor procedure is generally not payable as a separate service.
• 90-day global surgical period (for major procedures) includes one preoperative day. An E/M on the day of the procedure is generally not payable as a separate service. Examples of 90-day global surgical period procedures are CPT codes 15110 and 15115.

To view the global surgical period affiliated with any covered surgical procedures on the Medicare Physician Fee Schedule (MPFS), use the “Look-Up Tool” on the CMS website (visit www.cms.gov/apps/physician-fee-schedule/overview.aspx):

• Field 16 of the MPFS database provides the postoperative periods that apply to each surgical procedure. The payment rules for surgical procedures apply to codes with entries of “000,” “010,” “090,” and, sometimes, “YYY.”
• Codes with “090” in Field 16 are major surgeries. Codes with “000” or “010” are either minor surgical procedures or endoscopies.
• Codes with “YYY” are Medicare Part A/B Medicare Administrative Contractor (MAC) B-priced codes, for which A/B MACs (B) determine the global period (the global period for these codes will be 0, 10, or 90 days). NOTE: Not all A/B MAC B-priced codes have a “YYY” global surgical indicator; sometimes the global period is specified.
• While codes with “ZZZ” are surgical codes, they are add-on codes that are always billed with another service. There is no postoperative work included in the MPFS payment for the “ZZZ” codes. Payment is made for both the primary and the add-on codes, and the global period assigned is applied to the primary code.

Coding Guidelines Pertaining to Modifier -25

“Modifier -25 may be appended to E&M services reported with minor surgical procedures (global period of ‘000’ or ‘010’ days) or procedures not covered by global surgery rules (global indicator of ‘XXX’). Since minor surgical procedures and ‘XXX’ procedures include pre-procedure, intra-procedure, and post-procedure work inherent in the procedure, the provider should 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 whether the patient is a new or an established patient.”¹ 

“The CPT codes for procedures do include the evaluation services necessary prior to the performance of the procedure (eg, assessing the site/condition of the problem area, explaining the procedure, obtaining informed consent); however, when significant and identifiable (ie, key components/counseling) E/M services are performed, these services are not included in the descriptor for the procedure or service performed. It’s important to note the diagnosis reported with both the procedure/service and E/M service need not be different if the same diagnosis accurately describes the reasons for the encounter and the procedure.”² 

“If a procedure has a global period of ‘000’ or ‘010’ days, it’s defined as a ‘minor surgical procedure.’ In general, E/M services on the same date of service as the 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 should 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 E/M service and minor surgical procedure do not require different diagnoses. If a minor surgical procedure is performed on a new patient, the same rules for reporting E/M services apply. The fact that the patient is ‘new’ to the provider is not sufficient alone to justify reporting an E/M service on the same date of service as a minor surgical procedure.”¹ 

A Note About NCCI Edits 

The National Correct Coding Initiative (NCCI) procedure-to-procedure (PTP) code pair edits, medically unlikely edit tables, and NCCI manual are accessed through the NCCI edits web site (www.cms.gov/medicare/coding/nationalcorrectcodinited/index.html). Once there, click the “PTP Coding Edits” link on the left side. The “Practitioner PTP” links on the bottom of the page are for physicians and other qualified healthcare professionals. The “Hospital PTP” links are for the hospital and HOPD. 

The PTP code pairs are presented in two columns. If a provider submits two codes of an NCCI edit pair for payment for the same beneficiary on the same date of service, the code in Column 1 is eligible for payment and the code in Column 2 is not eligible for payment. However, if both codes are clinically appropriate, are on separate anatomic locations, and an appropriate NCCI-associated modifier is appended to the appropriate codes, the codes in both columns may be eligible for payment. Supporting documentation must be in the beneficiary’s medical record. The definitions for all of the NCCI edit columns in the PTP code pairs are:

• Column 1 indicates the payable code. 
• Column 2 indicates the code that is not payable with this particular Column-1 code, unless a modifier is permitted and submitted. 
• Column 3 indicates if the edit was in existence prior to 1996. 
• Column 4 indicates the effective date of the edit (year, month, date). 
• Column 5 indicates the deletion date of the edit (year, month, date). 
• Column 6 indicates if use of a modifier is permitted. 
• Column 7 provides the underlying basis for each PTP edit.

Following are two examples that show NCCI edits for E/M codes when reported on the same claim with Code 11042 - surgical debridement of subcutaneous tissue and with Code 15275 - application of cellular and tissue-based products to the foot:

Notice the E/M codes in Column 2 are not payable with the two minor wound care procedures in Column 1, unless the E/M pertains to a significant and separately identifiable service and Modifier -25 is reported and submitted. 

Now, let’s review an example of incorrect use of Modifier -25:

During a patient encounter on the same day, the physician debrides the skin and subcutaneous tissues (CPT Code 11042, 0 global days). The physician submits CPT codes 99213-25 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.  

The correct coding for this example is 11042 only because the E/M services are included in the minor procedure 11042. 

Future of Modifier -25 Scrutiny

The 2017 MPFS final rule provides further evidence that Modifier -25 will continue to be scrutinized. CMS notes that it will be reviewing 19 minor procedures with 0-day global surgical periods that were reported with an E/M code using Modifier -25. Below is an excerpt from the Federal Register ([FR] Vol. 81, No. 220, Nov. 15, 2016, Rules and Regulations, Page 80204):

Calendar Year (CY) 2017 Identification and Review of Potentially Misvalued Services That Are Typically Billed With An E/M Service With Modifier -25: “Because routine E/M is included in the valuation of codes with 0-, 10-, and 90-day global periods, Medicare only makes separate payment for E/M services that are provided in excess of those considered included in the global procedure. In such cases, the physician would report the additional E/M service with Modifier -25, which is defined as ‘a significant, separately identifiable E/M service performed by the same physician on the day of a procedure above and beyond other services provided or beyond the usual pre-service and post-service care associated with the procedure that was performed.’ Modifier -25 allows physicians to be paid for E/M services that would otherwise be denied as bundled. In reviewing misvalued codes, both CMS and the Relative Value Scale Update Committee have often considered how frequently particular codes are reported with E/M codes to account for potential overlap in resources. Some stakeholders have expressed concern with this policy, especially with regard to the valuation of 0-day global services that are typically billed with a separate E/M service with the use of Modifier -25. For our CY 2017 proposal (81 FR 46187), we investigated Medicare claims data for CY 2015 and found that 19% of the codes that described 0-day global services were billed over 50% of the time with an E/M with Modifier -25. Since routine E/M is included in the valuation of 0-day global services, we believed that the routine billing of separate E/M services may have indicated a possible problem with the valuation of the bundle, which is intended to include all the routine care associated with the service. In the proposed rule (81 FR 46187), we stated that reviewing the procedure codes typically billed with an E/M with Modifier -25 may be one avenue to appropriate valuation for these services. Therefore, we developed and proposed a screen for potentially misvalued codes that identified 0-day global codes billed with an E/M 50% of the time or more, on the same day of service, with the same physician and same beneficiary. We included a list of codes with total allowed services > 20,000. There are 83 codes that met the proposed criteria for the screen and were proposed as potentially misvalued. We also sought comment regarding additional ways to address appropriate valuations for all services that are typically billed with an E/M with Modifier -25.”

Summary

Modifier -25 monitoring is here to stay. It will continue to be audited by private and governmental payers. Based on the information in this article, wound care providers should have a bit more information to assist in deciding whether or not to use Modifier -25. Remember, there are appropriate uses for Modifier -25, but physicians and HOPDs must exercise caution when using it on the same date of service with minor procedures that have a 0- or 10-day global surgical period. Many wound care professionals’ E/M services may, in fact, be part of the minor surgical procedure codes as pointed out in the global surgical period definitions, unless the E/M services are documented and are provided on a totally different problem than the original complaint for that particular visit. 

Donna Cartwright is senior director of strategic reimbursement for Integra LifeSciences Corp., Plainsboro, NJ. She’s approved as a certified trainer on ICD-10-CM by the American Health Information Management Association and has been designated as a fellow of the American Health Information Management Association. 

References

1. National Correct Coding Initiative Policy Manual. Chapter 1. Evaluation and Management Services. Centers for Medicare & Medicaid Services.

2. Appropriate Use of Modifier -25. CPT Assistant. 1998. American Medical Association.

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