To 25 or not? Part one

Cracking the Code

Alexander Miller

Dr. Miller, who is in private practice in Yorba Linda, California, represents the American Academy of Dermatology on the AMA-CPT Advisory Committee.

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An established patient comes in complaining of a steadily enlarging, friable papulonodule on the nose. You obtain a history pertaining to the growth, query the patient concerning previous sun exposure, examine and palpate the lesion, discuss your presumptive diagnosis of a basal cell carcinoma, recommend a biopsy, obtain informed consent, do the biopsy, and instruct the patient on aftercare. You did a significant amount of evaluation and management (E/M) service. In addition to the 11100 biopsy charge, is it appropriate to additionally bill for a 99212 or 99213 established patient visit with an appended 25 modifier?

The CPT tackles the identification of a separate E/M service delivered on the day of a procedure by providing a 25 modifier to be appended to the appropriate E/M code. The modifier is defined by the CPT as: “Significant, Separately Identifiable Evaluation and Management Service by the Same Physician or Other Qualified Health Care Professional on the Same Day of the Procedure or Other Service.” It is appropriate to use the modifier to distinguish billing for E/M services beyond those included in the valuation of minor surgical procedures.

There are several questions to answer in deciding whether a 25 modifier is appropriate to the service provided. These are delineated below and will be explained individually.

  • What is the insurer’s payment policy regarding modifier 25?
  • Is the patient a new or established patient?
  • Was a minor surgical procedure (one with a zero- or 10-day global surgical package) done?
  • Was an E/M service done that is beyond that included in the procedure code valuation?
  • Did you appropriately document the separate E/M service? [pagebreak]

Medicare contractors recognize and pay in full for services appropriately billed with a 25 modifier. However, some private insurance carriers do not follow CPT guidelines or may have specific billing or reimbursement peculiarities that you must recognize in order to be reimbursed fairly. Specifically, some insurers insist upon paper billing with supporting chart documentation to be submitted when billing with a 25 modifier. Others may require that a 25 modifier be appended to new patient visits. There have also been attempts at reducing the reimbursement for a procedure when an E/M service is concomitantly billed. It is therefore imperative that you or a reliable designee review individual insurers’ policies and procedures dealing with modifiers to determine how billing should be done and whether you are likely to be paid for E/M services with 25 modifier use. Additionally, careful tracking of the insurer’s payment explanations of benefits may uncover sudden shifts in 25 reimbursement patterns.

Medicare policy specifies that a 25 modifier should not be appended to new patient visits, as these codes are excluded from restrictions based on the global surgical package. In such instances, when billing Medicare, bill the procedure code and an appropriate new patient visit code (99201-99205) without any modifier. (Dermatologists who use them should be aware that infusion and injection (96401-96417) and photodynamic therapy (96567) codes are not surgical codes, and a 25 modifier is needed when billing a new patient visit along with these codes.) As mentioned, some private insurers may have different policies.

A significant E/M service may qualify for billing with an E/M code along with a 25 modifier only when a minor surgical procedure with a zero- or 10-day global period is done on the same day. One must therefore know the global surgical periods for surgical series codes. The chart below summarizes the dermatology-pertinent global periods. [pagebreak]

A detailed listing of global surgical periods for all surgical codes may be accessed on the CMS website.

Once on the above Web page you must select appropriate search criteria:

  • Under Type of Information, click on Payment Policy Indicators.
  • Under Select HCPS Criteria, select a single, a list, or a range of codes.
  • Under Policy Indicators, type in the single, multiple, or range of CPT codes.
  • Under Modifier, select Global OR Physicians Professional Service.
  • Submit your request and you will see a listing of codes, their short descriptions, and the global periods.

The global periods are most commonly listed as: 000, 010, 090, or ZZZ. ZZZ refers to an add-on code (such as additional biopsy, 11101). The primary service code (in this case, 11100) will have the global period numerically specified. Keep in mind that some individual payers may not follow the Medicare global periods guidelines and/or may specify different global periods. [pagebreak]

Next, you must determine whether a significant service beyond that included in the procedure valuation has been done. Both minor and major surgical procedures contain a component of cognitive, evaluation and management services. The exact amount of E/M service incorporated in a surgical code varies by code. In general, a surgical code valuation includes at least the following components:

  • An assessment of the lesion or problem area.
  • An explanation of the procedure.
  • Informed consent.
  • Postoperative care instructions.

Lastly, if a service is not adequately documented, then there is no proof that it has actually been done. Lack of adequate chart documentation is a major reason for payment denials following chart audits.

Keep in mind that although dermatologists are recognized as the highest legitimate billers of E/M visits along with surgical procedures, routine, indiscriminate use of the 25 modifier will cast you as a statistical outlier. That is the surest way to an audit.

In Part 2 of “To 25 or Not?” next month, I will discuss specific tactics and scenarios for determining appropriate uses of the 25 modifier.