Modifier 25 – when it applies and what’s changing with Anthem

by Marilyn Rissmiller, CMS Senior Director of Health Care Financing

Accurate coding and documentation are still important to ensure you receive appropriate reimbursement for the services you provide your patients. The issues of coding accuracy and appropriate documentation are not just concerns of the federal programs; more commercial insurers are also taking a closer look at your claims as demonstrated by Anthem’s announcement concerning use of modifier 25.

Anthem announced in a bulletin earlier this year that they will deny an “…evaluation and management service with modifier 25 same day as a procedure when a prior E/M service for the same or similar service has occurred.” Colorado Medical Society President Deb Parsons, MD, FACP, and CMS staff met with Anthem’s medical director Elizabeth Kraft, MD, to gain a better understanding of how this policy will be implemented.

We were told that Anthem will look back in the patient’s claims history to see if the same physician has billed for an E/M visit for the same or similar diagnosis within the last 60 days. If there is a prior visit, and both E/M visits and the minor procedure all have the same diagnosis code (or one that is in the same “family” of diagnoses codes), the system will automatically deny the E/M visit that is reported with modifier 25. These denials can be appealed if the physician believes they were in error by submitting supporting documentation.

A modifier 25 refresher

You don’t just put a modifier 25 on an E/M visit and report it with every minor procedure. Modifier 25 is defined as a significant, separately identifiable Evaluation and Management (E/M) service by the same physician or other qualified health care professional on the same day of the procedure or other service.

If a procedure has a global period of 000 or 010 days, it is defined as a minor surgical procedure. In general, E/M services on the same day as a 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.

What’s significant and separately identifiable?

If, in addition to the procedure, the physician performs an E/M service that is beyond the usual pre-procedure, intra-procedure and post-procedure associated care, the E/M may be reported with modifier 25 appended.

The E/M service must be appropriately documented and unrelated to the decision to perform the minor surgical procedure. In other words, the pre-procedure work includes explaining the procedure to the patient and/or family member and discussing possible complications; the post-procedure work includes applying a dressing, monitoring for immediate side effects, providing recommendations on activities/modifications, and counseling the patient and/or family member about signs and symptoms of possible complications.

The E/M service must be significant, the documentation must substantiate this, and the physician work must be medically necessary. Did you perform all of the key components of a problem-focused visit, and could the E/M service stand on its own as a billable service? (Your documentation must meet the requirements for the code level reported.) Did you perform work beyond that associated with the pre- and post-services associated with the minor procedure? Would the problem addressed require treatment with a prescription or necessitate another visit to address it? These are some of the things to consider before billing an E/M visit with modifier 25 on the same day as a minor procedure.

Unlike Medicare, Anthem does require that the diagnosis code reported for the E/M service and the minor procedure are different. Be sure to report the correct diagnosis code associated with the problem addressed in the E/M visit and the correct diagnosis code for the specific procedure performed. This includes ensuring that the diagnosis pointer for the visit and the diagnosis pointer for the procedure are linked to the correct ICD-10 diagnosis codes on the claim. (If this doesn’t make sense to you, ask your biller.)

In news from other payers

UnitedHealthcare (UHC) announced that they will be eliminating reimbursement for consultation codes as part of an overall effort by UHC to “modernize” their physician contracts to align with Medicare. It was noted that the Centers for Medicare and Medicaid Services had made upward adjustments in E/M payments in 2010 to account for discontinuation of payment for consultation codes (hence, the “budget neutrality” of the federal CMS payment policy change).

The UHC reimbursement policy team indicated that they will be following this increase in E/M RVUs to balance out
the elimination of payment for consultation codes. To ensure that you are receiving the increased E/M RVU values physicians should make sure that your UHC contracted fee schedule is based on the federal CMS’ 2010 or later
fee schedule.


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