Notification



Notification Issue Date:



Claim Payment 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 #:03.00.06p

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

Application of Claim Payment Policy is determined by benefits and contracts. Benefits may vary based on product line, group or contract. Medical necessity determination applies only if the benefit exists and no contract exclusions are applicable. Individual member benefits must be verified.

In products where members are able to self-refer to providers for care and services, members are advised to use participating providers in order to receive the highest level of benefits.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.

For more information on how Claim Payment Policy Bulletins are developed, go to the About This Site section of this Medical Policy Web site.



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 procedure.
    • 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.

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.
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 pre-operative 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® 2018 Professional Edition: Spiralbound.

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

Optum360. 2018 Understanding Modifiers: Softbound.




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


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

03.00.06p:
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

Revisions from 03.00.06o
01/21/2018This 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


Effective 10/05/2017 this policy has been updated to the new policy template format.


Version Effective Date: 01/01/2019
Version Issued Date: 02/13/2019
Version Reissued Date: N/A

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