MA PPO

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
MA03.003g


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.

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.

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

CPT Procedure Code Number(s)
See Attachments A and B

ICD - 10 Procedure Code Number(s)
N/A

ICD - 10 Diagnosis Code Number(s)
N/A

HCPCS Level II Code Number(s)
N/A

Revenue Code Number(s)
N/A

Modifiers

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.


Policy History

1/1/2020
1/6/2020
MA03.003
Claim Payment Policy Bulletin
Medicare Advantage
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Yes