DRG Coding Advisor-It's time to think about modifier -25 changes
DRG Coding Advisor-It's time to think about modifier -25 changes
If you want extra money, put it in the record
One of the changes in coding procedures contained in the Health Care Financing Admin istration's (HCFA) new Physician 2000 fee schedule pertains to the use of the -25 modifier in connection with an evaluation and management (E/M) code.
Previously, a significant, separately identifiable E/M service had to be furnished before a separate procedure with a global period of 0, 10, or 90 days before the E/M service also will be paid in addition to the procedure.
The current coding method for indicating that the E/M service is not related to the surgical procedure is to append modifier -25 (significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) to the E/M service code.
HCFA's new rule says for procedures that have a global period indicator of "XXX," when a significant separately identifiable E/M service is furnished at the same time by the same physician, the physician must append to the E/M service code the modifier -25. (See box, at right.)
HCFA justifies this new policy by arguing every procedure already has some kind of inherent E/M component. Therefore, for an E/M service to be paid separately, a significant separately identifiable service should be documented in the medical record.
"In other words, we want to prevent the practice of physicians reporting an E/M service code for the inherent evaluative component of the procedure itself," states the final regulation.
HCFA says it will not require the routine use of modifier -25 with all procedures having a global indicator of "XXX.'' Instead, it plans to identify specific codes with which the E/M service furnished would need to be documented as being significant and separately identifiable with a -25 modifier.
Responding to questions about whether this new modifier policy applies to diagnostic tests, immunizations, and laboratory and pathology services, HCFA notes it is "not making a blanket requirement that modifier -25 be used with every code in a specific category of services."
Instead, it "will implement this coding policy for specific . . . codes when we believe there is abuse — or the potential for abuse — in the reporting of an E/M service."
As such, HCFA also says it will give physician specialties the opportunity to review and comment before it implements any edits for a specific code combination.
HCFA hopes to begin to identify and include specific procedure codes for which the modifier -25 will be required in the Correct Coding Initia tive edits due out in October 2000.
Meantime, HCFA is encouraging all practitioners to familiarize themselves with these modifiers and use them when applicable.
Tip: Some specialties rarely furnish a service designated as one with no global period without performing services represented by an E/M visit code. HCFA's coding gurus agree an identifiable E/M service may be furnished with many procedures where no global period applies.
However, HCFA auditors will be looking for instances in which a minimum amount of evaluation is done as a "inherent component of the service or procedure." In such instances, HCFA does not feel it is appropriate to report a minimum level E/M code in addition to the service or procedure.
In other words, if you want to try to add a questionable low-level E/M fee onto a specific service or procedure, HCFA is probably going to question the claim.
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