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by Rez Legal | July 17, 2018 | 0 Comment

Federal Government scrutiny over healthcare providers’ use of CPT Code Modifier 25 is not new, but we are seeing an uptick in enforcement.  The U.S. Department of Health and Human Services, Office of Inspector General (“OIG”), has targeted the use of Modifier 25 in its yearly work plans. The OIG’s yearly work plans outline the current focus areas of the OIG and lead to increased scrutiny by the OIG of those areas.

This month, FWC Urogynecology, LLC agreed to pay $1.7 million to settle allegations of False Claims Act violations involving misuse of Modifier 25.  Another notable settlement involving the misuse of Modifier 25 is the $4.1 million civil settlement between Georgia Cancer Specialists I, PC and the U.S. Department of Justice in 2012.  In addition to these civil settlements, Medicare Recovery Audit Contractors (RACs) have historically targeted this code in their audits of Evaluation and Management (“E/M”) services billed during global surgery periods for major and minor procedures.

Medicare reimbursement rules generally do not allow for additional payments for E/M services performed on the same day as another service or procedure.  Modifier 25 is appropriately used when an E/M service is performed on the same day another service or procedure is provided to the patient by the same provider.  The separate E/M service must be significant and separately identifiable and must go above and beyond the other service or procedure provided.  When determining whether Modifier 25 is appropriate, the following requirements must be met:

  • A procedure must be performed on the same day as the E/M service; and
  • The E/M service must be significant and separately identifiable.

Without the modifier, the E/M service is typically bundled into the visit.  By using the modifier, the provider may receive separate reimbursement for the E/M service.  It is also important to note that the separate, significant E/M service may be prompted by the condition for which the other service or procedure was provided. A separate diagnosis code is not required.  However, the provider’s documentation must meet the requirements to bill an E/M code, and the E/M service must be medically necessary.

The following are examples of when Modifier 25 is appropriately used.

Scenario 1:  A patient visits a cardiologist for an appointment due to intermittent chest pain that is exacerbated with exercise.  After the physician completes the office visit, the physician determines the patient needs a stress test that is performed on the same day.  Thus, the physician will bill an E/M Code of 99214 (depending on the level of the visit) and append Modifier 25.  In addition, the physician would also bill a 93015 for the stress test.

Scenario 2:  Mom arranges a visit for her child who has a fever and ear pain.  The physician completes a detailed history and problem-focused exam.  The doctor notices the child is experiencing a severe inner ear infection.  The physician administers Ceftriaxone Sodium and issues a final diagnosis of acute suppurative otitis media without rupture of the eardrum.  The E/M visit is appropriately coded as a 99213 with Modifier 25 appended.  In addition, Code 90777 and J0696 (for the administration of Ceftriaxone) could also be billed for the visit for the separate procedure performed.

Scenario 3:  A patient is evaluated for treatment of neck pain.  The patient received trigger point injections for the neck pain.  The patient was also evaluated for high blood pressure.  New medications were prescribed to control the patient’s high blood pressure.  Modifier 25 is appropriately appended to the E/M visit for the evaluation and treatment of the patient’s elevated blood pressure.

Some examples of when the use of Modifier 25 is not appropriate include the following:

  • For post-operative services performed related to the previous surgery;
  • If there is only an E/M service performed alone with no procedure or separate service on the same day;
  • Modifier 25 is used on a day when a “major” procedure is performed (subject to 90-day global rule);
  • The patient came in for a scheduled procedure only.  For example, if a patient comes in for a stress test and the physician completes a history and physical as part of that scheduled procedure, Modifier 25 should not be used because the history and physical is part of performing the stress test;
  • Use of Modifier 25 on a regular basis versus on a sporadic or periodic basis; and
  • When the E/M visit is integral to accomplishing the procedure and not a significant, separate service.
  • Example:  A patient was scheduled for debridement of skin and subcutaneous tissues (CPT Code 11042). The physician also spent time to evaluate and examine the patient at the visit to determine whether to proceed with debridement.  In this case, the E/M service is not separately reimbursable from the surgical procedure because the physician’s evaluation was part of the surgical procedure.  The only code that should be billed is 11042.

False Claims Act cases can initiate from a variety of sources including: government data mining, payor audits or whistleblower lawsuits.  The Affordable Care Act mandates compliance programs for Medicare and Medicaid providers.  It is imperative that health care providers have an effective compliance plan in place and perform regular audits of their coding and billing to make sure that the practice has accurate coding and complete medical record documentation that supports the diagnoses and services reported on the claim form for reimbursement.

For more information regarding this Client Alert, or if you need a compliance plan for your practice, or you need assistance with analyzing your practice’s compliance with these billing rules, please contact either Elizabeth Shaw by phone at 904-567-1175 or by e-mail at liz@rezlegal.com or Samantha Prokop by phone at 904-638-3065 or by e-mail at  samantha@rezlegal.com.

**This Legal Bulletin is for informational purposes only and not intended as legal advice for specific situations.