Notification



Notification Issue Date:



Medicare Advantage Policy

Title:Modifier 25: 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
Policy #:MA03.003g

This policy is applicable to the Company’s Medicare Advantage products only. Policies that are applicable to the Company’s commercial products are accessible via a separate commercial policy database.


The Company makes decisions on coverage based on the Centers for Medicare and Medicaid Services (CMS) regulations and guidance, benefit plan documents and contracts, and the member’s medical history and condition. If CMS does not have a position addressing a service, the Company makes decisions based on Company Policy Bulletins. Benefits may vary based on contract, and individual member benefits must be verified. The Company determines medical necessity only if the benefit exists and no contract exclusions are applicable. Although the Medicare Advantage Policy Bulletin is consistent with Medicare’s regulations and guidance, the Company’s payment methodology may differ from Medicare.

When services can be administered in various settings, the Company reserves the right to reimburse only those services that are furnished in the most appropriate and cost-effective setting that is appropriate to the member’s medical needs and condition. This decision is based on the member’s current medical condition and any required monitoring or additional services that may coincide with the delivery of this service.


This Policy Bulletin document describes the status of CMS coverage, medical terminology, and/or benefit plan documents and contracts at the time the document was developed. This Policy Bulletin will be reviewed regularly and be updated as Medicare changes their regulations and guidance, scientific and medical literature becomes available, and/or the benefit plan documents and/or contracts are changed.



Policy

Coverage is subject to the terms, conditions, and limitations of the member's Evidence of Coverage.

This policy applies to professional providers or other qualified health care providers billing on a CMS-1500 claim form or the electronic equivalent, 837p, for members enrolled in all Company products.

When an evaluation and management (E&M) service is performed on the same day, by the same professional provider or other qualified health care provider, that a procedure or other service is performed because the individual's condition or symptoms require a significant, separately identifiable E&M service, the E&M service should be appended with modifier 25.
  • When modifier 25 is appropriately appended to an E&M service and is submitted on the same date of service, by the same professional provider or other qualified health care provider, as a minor procedure, the E&M service is reimbursed at 50 percent of the applicable fee schedule amount.
    • A minor procedure has a zero-day or 10-day postoperative period.
    • Procedures without a zero-day or 10-day postoperative period (e.g., immunizations and vaccines, and their associated administration services, as well as EKGs and pulmonary function testing, etc.), are not considered minor procedures and are not subject to the 50 percent reduction of this policy.
    • Refer to Attachment A for a list of the specific problem-focused E&M codes and minor procedure codes.
  • When modifier 25 is appropriately appended to a problem-focused E&M service and is submitted on the same date of service, by the same professional provider or other qualified health care provider, as a preventive E&M, the problem-focused E&M service is reimbursed at 50 percent of the applicable fee schedule amount.
    • Refer to Attachment B for a list of the specific problem-focused E&M codes and preventive E&M codes.

It is appropriate to append modifier 25 to an E&M service in the following circumstances:
  • The E&M service is a significant and separately identifiable service performed by the same professional provider or other qualified health care provider on the same day of the procedure or other service.
    • Different diagnoses are not required for reporting E&M services on the same day as a procedure or other service.
  • The E&M service is performed by the same professional provider or other qualified health care provider on the day of a minor procedure.
    • A minor procedure has a zero-day or 10-day postoperative period.
  • The E&M service is beyond the usual pre-operative and postoperative care associated with the procedure or other service.
  • The problem-focused E&M service is performed at the same time as a preventive care visit.
  • The E&M service is reported with preoperative critical care codes within a global surgical period.

It is inappropriate to append modifier 25 to an E&M service in the following circumstances:
  • The initial decision to perform a major procedure is made during an E&M service that occurs on the day before or the day of a major surgery.
    • A major procedure has a 90-day postoperative period.
    • Modifier 57 (decision for surgery) should be used in this instance.
  • The E&M service is reported by a professional provider or other qualified health care provider other than the professional provider or other qualified health care provider who performed the procedure.
  • The E&M service is performed on a different day than the procedure.
  • The modifier is reported with an E&M service that is within the usual pre-operative or postoperative care associated with the procedure.
  • The modifier is reported with a non-E&M service.
  • The reason for the office visit was strictly for the minor procedure since reimbursement for the procedure includes the related preoperative and postoperative service.
  • The physician performs ventilation management in addition to an E&M service.
  • The preventive E&M service is performed at the same time as a preventive care visit (e.g., a preventive E&M service and a routine gynecological exam performed on the same date of service and by the same professional provider or other qualified health care provider). Since both represent preventive visits, only one should be reported.
  • The routine or serial use of the modifier is reported without supporting clinical documentation.

REQUIRED DOCUMENTATION

When appending modifier 25 to an E&M service billed on the same date of service as a procedure or other service, documentation for the additional E&M must be entered in a separate section of the medical record in order to validate the separate and distinct nature of the E&M service. The documentation should be clearly distinct from the documentation related to the procedure performed on the same date of service. The additional E&M service must be able to stand alone as a billable service with no overlapping of key E&M components (medical history, medical examination, and medical decision-making performed). The record must include documentation for all services provided on the specific date of service. The record should not include any documentation from previous dates of service (i.e., cloning), unless related to the specific date of service being reported.

The individual's medical record must reflect the medical necessity for the care provided. These medical records may include, but are not limited to: records from the professional provider's office, hospital, nursing home, home health agencies, therapies, and test reports.

The Company may conduct reviews and audits of services to our members, regardless of the participation status of the provider. All documentation is to be available to the Company upon request. Failure to produce the requested information may result in a denial for the service.
Policy Guidelines

This policy is consistent with Medicare's reporting requirements. The Company's payment methodology may differ from Medicare.

Description

In certain instances, it may be necessary for professional providers or other qualified health care providers to perform an evaluation and management (E&M) service on the same day that a procedure or other service is performed. When an individual's condition or symptoms require a significant, separately identifiable E&M service above and beyond the other service provided, or beyond the usual preoperative and postoperative care associated with the procedure that was performed on that day, the E&M service should be appended with modifier 25.
References

American Medical Association (AMA). CPT Professional Edition: Current Procedural Terminology (Current Procedural Terminology, Professional Ed.; 2017.

Centers for Medicare & Medicaid Services (CMS). Medicare Learning Network. Global Surgery Fact Sheet. Available at: https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/GloballSurgery-ICN907166.pdf. Accessed on April 4, 2018.

2017 Understanding Modifiers (Optum Learning Series) (Optum Learning: Coding & Reimbursement Educational); 2017th Edition.



Coding

Inclusion of a code in this table does not imply reimbursement. Eligibility, benefits, limitations, exclusions, precertification/referral requirements, provider contracts, and Company policies apply.

The codes listed below are updated on a regular basis, in accordance with nationally accepted coding guidelines. Therefore, this policy applies to any and all future applicable coding changes, revisions, or updates.

In order to ensure optimal reimbursement, all health care services, devices, and pharmaceuticals should be reported using the billing codes and modifiers that most accurately represent the services rendered, unless otherwise directed by the Company.

The Coding Table lists any CPT, ICD-9, ICD-10, and HCPCS billing codes related only to the specific policy in which they appear.

CPT Procedure Code Number(s)

See Attachments A and B


Professional and outpatient claims with a date of service on or before September 30, 2015, must be billed using ICD-9 codes. Professional and outpatient claims with a date of service on or after October 1, 2015, must be billed using ICD-10 codes.

Facility/Institutional inpatient claims with a date of discharge on or before September 30, 2015, must be billed with ICD-9 codes. Facility/Institutional inpatient claims with a date of discharge on or after October 1, 2015, must be billed with ICD-10 codes.


ICD - 10 Procedure Code Number(s)

N/A


Professional and outpatient claims with a date of service on or before September 30, 2015, must be billed using ICD-9 codes. Professional and outpatient claims with a date of service on or after October 1, 2015, must be billed using ICD-10 codes.

Facility/Institutional inpatient claims with a date of discharge on or before September 30, 2015, must be billed with ICD-9 codes. Facility/Institutional inpatient claims with a date of discharge on or after October 1, 2015, must be billed with ICD-10 codes.


ICD -10 Diagnosis Code Number(s)

N/A


HCPCS Level II Code Number(s)

N/A


Revenue Code Number(s)

N/A


Misc Code

Modifier:

Modifier 25 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


Coding and Billing Requirements

BILLING REQUIREMENTS

The company requires that professional providers or other qualified health care providers report on one CMS-1500 claim form or the electronic equivalent, 837p when two or more procedures or services were performed for the same patient, by the same professional provider or other qualified health care provider, and on the same date of service.

Inclusion of a code in this policy does not guarantee reimbursement. Eligibility, benefits, limitations, exclusions, precertification/referral requirements, provider contracts, and applicable policies apply.

Cross References

Attachment A: Modifier 25: 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
Description: E&M codes appended with modifier 25 should be reimbursed at 50 percent of the applicable fee schedule amount when submitted on the same date of service, by the same professional provider or other qualified health care provider, as a minor procedure.

Attachment B: Modifier 25: 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
Description: Problem-focused E&M codes appended with modifier 25 should be reimbursed at 50 percent of the applicable fee schedule amount when submitted on the same date of service, by the same professional provider or other qualified health care provider, as a preventive E&M.







Policy History

MA03.00G
01/01/2019This version of the policy will become effective 01/01/2019.

The following CPT & HCPCS codes have been added to this policy: 33016, 37765, 37766, 33017, 33018, 33019, 49013, 49014, 62328, 62329, 64451, 64454, 64624, 64625, 90912, 92992, 92993

The following CPT codes have been deleted from this policy: 33010, 33011, 34812, 64402, 64410, 64413, 64421, 90911

The following CPT code narratives have been revised in this policy: 31233, 31235, 31292, 31293, 31294, 31295, 31296, 31297, 31298, 62270, 62272, 64400, 64405, 64408, 64415, 64416, 64417, 64418, 64420, 64421, 64425, 64430, 64435, 64445, 64446, 64447, 64448, 64449, 64450

MA03.003f:
01/01/2019This version of the policy will become effective 01/01/2019.

The following CPT & HCPCS codes have been added to this policy: G0460, 11102, 11104, 11106, 27369, 33285, 33286, 33289, 36572, 36573, 43762, 43763, 50436, 50437.

The following CPT codes have been deleted from this policy: 11100, 20005, 27370, 43760, 50395, 64508, 64550, 34812, 34820, 34833, 34834, 93561, 93562.

The following CPT code narratives have been revised in this policy: 36568, 36569, 36584.

REVISION FROM MA03.003e
08/01/2018This policy will become effective 08/01/2018. This policy was revised to remove the following CPT codes: 99241, 99242, 99243, 99244, 99245.

REVISION FROM MA03.003d
01/01/2018This policy has been identified for the CPT code update, effective 01/01/2018. The References were updated accordingly.

The following minor procedure CPT codes have been added to Attachment A of this policy: G0516, G0517, G0518, 0479T, 0481T, 0483T, 0484T, 0489T, 0490T, 0491T, 0499T, 30140, 31241, 31253, 31257, 31259, 31298, 32994, 36215, 36216, 36217, 36465, 36466, 36482, 38573, 55874, 96573, 96574

The following minor procedure CPT codes have been deleted from Attachment A of this policy: 29582, 29583, 36515, 55450, 64565

The following CPT code narratives have been revised from Attachment A of this policy:
17250, 31254, 31255, 31276, 31645, 31646, 32998, 34812, 34820, 34833, 34834, 36468, 36470, 36471, 36516, 64550, 99217, 99218, 99219, 99220

REVISION FROM MA03.003c
08/01/2017Revised policy number 03.00.06n was issued as a result of annual policy review, effective 08/01/2017. The References were updated accordingly. The policy was updated to be consistent with current template wording and format. The adoptable source for this policy is CMS.

The following language was added to the Policy section of this policy:

This policy applies to professional providers or other qualified health care providers billing on a CMS-1500 claim form or the electronic equivalent, 837p, for members enrolled in all Company products.

When an evaluation and management (E&M) service is performed on the same day, by the same professional provider or other qualified health care provider that a procedure or other service is performed because the individual's condition or symptoms require a significant, separately identifiable E&M service, the E&M service should be appended with modifier 25.
  • When modifier 25 is appropriately appended to an E&M service and is submitted on the same date of service, by the same professional provider or other qualified health care provider, as a minor procedure, the E&M service is reimbursed at 50 percent of the applicable fee schedule amount.
    • A minor procedure has a zero-day or 10-day postoperative period.
    • Procedures without a zero-day or 10-day postoperative period (e.g. Immunizations and vaccines, and their associated administration services, as well as EKGs and pulmonary function testing, etc.) are not considered minor procedures and are not subject to the 50 percent reduction of this policy.
    • Refer to Attachment A for a list of the specific problem-focused E&M codes and minor procedure codes.
  • When modifier 25 is appropriately appended to a problem-focused E&M service and is submitted on the same date of service, by the same professional provider or other qualified health care provider, as a preventive E&M, the problem-focused E&M service is reimbursed at 50 percent of the applicable fee schedule amount.
    • Refer to Attachment B for a list of the specific problem-focused E&M codes and preventive E&M codes.


REQUIRED DOCUMENTATION

When appending modifier 25 to an E&M service billed on the same date of service as a procedure or other service, documentation for the additional E&M must be entered in a separate section of the medical record in order to validate the separate and distinct nature of the E&M service. The documentation should be clearly distinct from the documentation related to the procedure performed on the same date of service. The additional E&M service must be able to stand alone as a billable service with no overlapping of key E&M components (medical history, medical examination, and medical decision-making performed). The record must include documentation for all services provided on the specific date of service. The record should not include any documentation from previous dates of service (i.e. coning), unless related to the specific date of service being reported.
BILLING REQUIREMENTS

The company requires that professional providers or other qualified health care providers report on one CMS-1500 claim form or the electronic equivalent, 837p when two or more procedures or services were performed for the same patient, by the same professional provider or other qualified health care provider, and on the same date of service.

Inclusion of a code in this policy does not guarantee reimbursement. Eligibility, benefits, limitations, exclusions, precertification/referral requirements, provider contracts, and applicable policies apply.

The following language was removed from this policy:

MEDICARE

This policy is consistent with Medicare's reporting requirements. The Company's payment methodology may differ from Medicare.

The following codes were removed from the CPT Procedure Code Number(s) and Narrative(s) section of this policy:

0188T 0189T 0359T 0360T 0361T 0362T 0363T 0364T 0365T 0366T 0367T 0368T 0369T 0370T 0371T 0372T 0373T 0374T 34839 92002 92004 92012 92014 96160 99024 99201 99202 99203 99204 99205 99211 99212 99213 99214 99215 99217 99218 99219 99220 99221 99222 99223 99224 99225 99226 99231 99232 99233 99234 99235 99236 99238 99239 99241 99242 99243 99244 99245 99251 99252 99253 99254 99255 99281 99282 99283 99284 99285 99288 99291 99292 99304 99305 99306 99307 99308 99309 99310 99315 99316 99318 99324 99325 99326 99327 99328 99334 99335 99336 99337 99339 99340 99341 99342 99343 99344 99345 99347 99348 99349 99350 99354 99355 99356 99357 99358 99359 99360 99363 99364 99366 99367 99368 99374 99375 99377 99378 99379 99380 99381 99382 99383 99384 99385 99386 99387 99391 99392 99393 99394 99395 99396 99397 99401 99402 99403 99404 99406 99407 99408 99409 99411 99412 99429 99441 99442 99443 99444 99446,99447,99448,99449,99450 99455 99456 99460 99461 99462 99463 99464 99465 99466 99467 99468 99469 99471 99472 99475 99476 99477 99478 99479 99480 99485 99486 99487 99489 99490 99495 99496 99497 99498 99499

The following codes were removed from the HCPCS Level II Code Number(s) and Narrative(s) section of this policy:

D9311 G0101 G0102 G0128 G0175 G0181 G0182 G0245 G0246 G0247 G0337 G0378 G0379 G0380 G0381 G0382 G0383 G0384 G0402 G0406 G0407 G0408 G0425 G0426 G0427 G0436 G0437 G0438 G0439 G0463 G0473 G0501 G0505 G0506 G0508 G0509 G9050 G9051 G9052 G9053 G9054 G9055 S0260 S0265 S0601 S0610 S0612 S0613 S9117 S9123 S9124 S9140 S9141 S9455

The following codes were added to Attachment A of this policy:

92002, 92004, 92012, 92014, 99201, 99202, 99203, 99204, 99205, 99211, 99212, 99213, 99214, 99215, 99217, 99218, 99219, 99220, 99224, 99225, 99226, 99241, 99242, 99243, 99244, 99245, 99281, 99282, 99283, 99284, 99285, 99318, 99324, 99325, 99326, 99327, 99328, 99334, 99335, 99336, 99341, 99342, 99343, 99344, 99345, 99347, 99348, 99349, 99350, 99381, 99382, 99383, 99384, 99385, 99386, 99387, 99391, 99392, 99393, 99394, 99395, 99396, 99397, 99401, 99402, 99403, 99404, 99411, 99412, G0101, G0402, G0463, S0610, S0612, S0613, G0438, G0439, G0380, G0381, G0382, G0383, G0384
The following codes were added to Attachment B of this policy:

Problem-Focused E&M Codes

99201, 99202, 99203, 99204, 99205, 99211, 99212, 99213, 99214, 99215, G0463

Preventive E&M Codes

99381, 99382, 99383, 99384, 99385, 99386, 99387, 99391, 99392, 99393, 99394, 99395, 99396, 99397, G0402, G0438, G0439

REVISION FROM MA03.003b
01/01/2017This is a a coding update policy.

REVISION FROM MA03.003a
01/21/2015This is a a coding update policy.

REVISION FROM MA03.003
01/01/2015This is a new policy.




Version Effective Date: 01/01/2020
Version Issued Date: 01/06/2020
Version Reissued Date: N/A