COMMON DOCUMENTATION ERRORS

Required Documentation That Was Deficient - Physical Exam

Component of the Documentation That Was Missing or Incomplete 

The missing information included:

* Previous diagnosis.

* An exam of the area of the spine involved in the diagnosis.

* Assessment of change in the patient’s condition since the last visit and an evaluation of treatment.

Plan of care - Component of the Documentation That Was Missing or Incomplete

The plan of care was incomplete in that it lacks specific treatment goals and objective measures to evaluate treatment effectiveness.

chiropractic X- RAY coverage

X-RAYS ORDERED/REFERRED BY A CHIROPRACTOR

Coverage of chiropractic services is specifically limited to treatment by means of manual manipulation. No other diagnostic or therapeutic service furnished by a chiropractor or under his order is covered. The X-ray may be used for documentation, but Medicare will make no payment to the Doctor of Medicine (MD) or Doctor of Osteopathy (DO) if the chiropractor orders the X-ray.

This clarifies the current policy regarding payment of diagnostic X-rays either ordered by or referred by a chiropractor. If a chiropractor directs or refers the patient to the radiologist to obtain an X-ray to demonstrate a subluxation prior to beginning treatment, and the radiologist performs the X-ray based upon the chiropractor’s evaluation of the patient, the radiologist should report the chiropractor as the ordering provider on the claim form. Medicare will deny the service as non-covered, the beneficiary will be responsible for payment, the ABN will not apply, and advance written notice will not be required.

CHIROPRACTORS BILLING FOR PHYSICAL THERAPY

Chiropractors billing for physical therapy services (CPT codes 97001–97799 and HCPCS code G0283) must bill with the appropriate modifier.

* GN – Services delivered under an outpatient speech-language pathology plan of care.

* GO – Services delivered under an outpatient occupational therapy plan of care.

* GP – Services delivered under an outpatient physical therapy plan of care.

Even though physical therapy billed by a chiropractor is a program exclusion, if one of the above modifiers is omitted from any of the codes referenced, the service will be rejected. This rejection would require the claim to be corrected and resubmitted.

CODING GUIDELINES

* The level of subluxation must be specified on the claim and must be listed as the primary diagnosis, i.e., cervical region (7391). The neuromusculoskeletal condition necessitating the treatment must be listed as the secondary diagnosis.

* Non-covered services provided by a chiropractor need not be billed to Medicare unless the patient requests the services be billed to obtain a denial for his supplemental insurance. The chiropractor may bill the services with specific procedure codes for the non-covered services, e.g., X-rays, laboratory tests, physical examinations or physical therapy. One exception to this situation exists: A chiropractor will still be required to bill Medicare for manipulations that exceed the norm and maintenance therapy.

CLAIM REQUIREMENTS

* The initial date of treatment must be documented in Item 14 of the CMS-1500 claim form or the electronic equivalent.

* If the subluxation is demonstrated by an X-ray, the X-ray date must be placed in Item 19 of the CMS-1500 claim form or the electronic equivalent.

Complete claim form instructions can be found at:

http://www.trailblazerhealth.com/Publications/Training Manual/claim form instructions.pdf

Chiropractic services CPT code 98940, 98941, 98942

Chiropractic services are subject to national regulation, which provides definitions, indications and limitations for Medicare payment of chiropractic service. Please see Medicare Benefit Manual sections referenced above for national definitions, indications and limitations.

Medicare expects that acute symptoms/signs due to subluxation or acute exacerbation/recurrence of symptoms/signs due to subluxation might be treated vigorously. Improvement in the patient’s symptoms is expected and in order for payment for chiropractic services to continue, should be demonstrated within a time frame consistent with the patient’s clinical presentation. 

Failure of the patient’s symptoms to improve accordingly or sustained worsening of symptoms should prompt referral of the patient for evaluation and/or treatment by an appropriate practitioner.

This LCD imposes diagnosis limitations that support diagnosis to procedure code automated denials. Medicare will allow up to 12 chiropractic manipulations per month and 30 chiropractic manipulation services per beneficiary per year. 

Despite allowing up to these maximums, each patient’s condition and response to treatment must medically warrant the number of services reported for payment, and Medicare does not expect that patients will routinely require the maximum allowable number of services. 

Additionally, Medicare requires the medical necessity for each service to be clearly demonstrated in the patient’s medical record. Covered diagnoses are displayed in four groups in this policy, with the groups being displayed in ascending specificity. Medicare does not expect that substantially more than the following numbers of treatments will usually be required:

Twelve (12) chiropractic manipulation treatments for Group A diagnoses.

Eighteen (18) chiropractic manipulation treatments for Group B diagnoses.

Twenty-four (24) chiropractic manipulation treatments for Group C diagnoses.

Thirty (30) chiropractic manipulation treatments for Group D diagnoses.

Notice: This LCD imposes diagnosis limitations that support diagnosis to procedure code automated denials. However, services performed for any given diagnosis must meet all of the indications and limitations stated in this policy, the general requirements for medical necessity as stated in CMS payment policy manuals, any and all existing CMS NCDs, and all Medicare payment rules.

As published in CMS IOM, Pub. 100-08, Section 13.5.1, to be covered under Medicare, a service shall be reasonable and necessary. When appropriate, contractors shall describe the circumstances under which the proposed LCD for the service is considered reasonable and necessary under Section 1862(a)(1)(A). Contractors shall consider a service to be reasonable and necessary if the contractor determines that the service is:

Safe and effective.

Not experimental or investigational (exception: routine costs of qualifying clinical trial services with dates of service on or after September 19, 2000, which meet the requirements of the clinical trials NCD are considered reasonable and necessary).

Appropriate, including the duration and frequency that is considered appropriate for the service, in terms of whether it is:

Furnished in accordance with accepted standards of medical practice for the diagnosis or treatment of the patient’s condition or to improve the function of a malformed body member. Furnished in a setting appropriate to the patient’s medical needs and condition. Ordered and furnished by qualified personnel. One that meets, but does not exceed, the patient’s medical need. At least as beneficial as an existing and available medically appropriate alternative.

CPT/HCPCS Codes

Note: Providers are reminded to refer to the long descriptors of the CPT codes in their CPT books. The American Medical Association (AMA) and the Centers for Medicare & Medicaid Services (CMS) 

require the use of short CPT descriptors in policies published on the Web. 98940©

Chiropractic manipulation

98941©

Chiropractic manipulation

98942©

Chiropractic manipulation

ICD-9-CM Codes That Support Medical Necessity

The CPT/HCPCS codes included in this LCD will be subjected to “procedure to diagnosis” editing. The following lists include only those diagnoses for which the identified CPT/HCPCS procedures are covered. If a covered diagnosis is not on the claim, the edit will automatically deny the service as not medically necessary.

Medicare is establishing the following limited coverage for CPT/HCPCS codes 98940, 98941 and 98942:

Billing and Coding Guide

This policy describes Optum’s requirements for reimbursement of CPT codes 98940, 98941, 98942 (Spinal Chiropractic Manipulative Treatment) and 98943 (Extraspinal Chiropractic Manipulative Treatment).

The purpose of this policy is to ensure that Optum reimburses for services that are billed and documented, without reimbursing for billing submission or data entry errors or for non-documented services.

Extraspinal Manipulation + Spinal Manipulation

Modifier -51 (Multiple Procedures) is not required to be appended to the extraspinal CMT procedural code (98943), when billed on the same date of service as a spinal CMT code (98940-98942). 

Modifier -51 (Multiple Procedures) does not need to be appended to the extraspinal CMT code (98943), when billed in conjunction with chiropractic manipulative treatment (CMT) codes (98940- 98943). According to “The CPT® Assistant” [December 2013], these are separate and distinct procedures and the use of modifier 51 does not apply. 

98940 Chiropractic manipulative treatment (CMT); spinal, one to two regions. Documentation must include a validated diagnosis for one or two spinal regions and support that manipulative treatment occurred in one to two regions of the spine (region as defined by CPT).

98941 Chiropractic manipulative treatment (CMT); spinal, three to four regions

Documentation must support that manipulative treatment occurred in three to four regions of the spine (region as defined by CPT) and one of the following:

1. validated diagnoses for three or four spinal regions

2. validated diagnoses for two spinal regions, plus one or two adjacent spinal regions with documented soft tissue and segmental findings 

CPT Code Description Documentation Requirement

98940 Chiropractic manipulative treatment (CMT) involving one to two spinal regions Medical record must document:

1. A complaint involving at least one spinal region;

2. an examination of the corresponding spinal region(s); AND

3. a diagnosis and manipulative treatment of a condition involving at least one spinal region.

Claim must record a diagnosis code (ICD-9) in the applicable region(s).

NCCI Edit

The below codes would not be paid separately if submitted with CPT code 98940 , Use appropriate Modifier.

64461 64463 64486 64487 64488 64489 95831 95832

95833 95834 95851 95852 96361 96366 96367 96368

97112 97124 97140 98926 98927 98928 98929 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 99281 99282 99283 99284 99285

99291  99304 99305 99306 99307 99308 99309 99310

99315 99316 99318 99324 99325 99326 99327 99328

99334 99335 99336 99337 99341 99342 99343 99344

99345 99347 99348 99349 99350 99455 99456 99460

99461 99462 99463 99465 99466 99468 99469 99471

99472  99475 99476 99477 99478 99479 99480 99485

99495  99496 99497 G0380 G0381 G0382 G0383 G0384

G0463  

Primary Diagnosis Codes Covered for: 739.0–739.5

Non-allopathic lesions, not elsewhere classified

Secondary Diagnosis Codes

Group A Diagnoses Covered for: 307.81

Tension headache

719.48*

Pain in joint, other specified sites

Note: When using 719.48*, you must specify spine as the site.

723.1

Cervicalgia

724.1–724.2

Other and unspecified disorders of back

724.5

Backache, unspecified

724.8

Other symptoms referable to back

728.85

Spasm of muscle

784.0

Headache

Group B Diagnoses Covered for: - 720.1

Spinal enthesopathy - 721.0–721.2

Spondylosis and allied disorders (arthritis, osteoarthritis, spondyloarthritis) - 721.6

Ankylosing vertebral hyperostosis - 721.90–721.91

Spondylosis of unspecified site - 724.79

Disorders of coccyx, coccygodynia - 729.1

Myalgia and myositis, unspecified - 729.4

Fasciitis, unspecified -  846.0–846.3

Sprains and strains of sacroiliac region - 846.8

Sprains and strains of other specified sites of sacroiliac region - 847.0–847.4

Sprains and strains of other and unspecified parts of back

Group C Diagnoses Covered for: 353.0–353.4

Nerve root and plexus disorders - 353.8

Other nerve root and plexus disorders - 722.91–722.93

Other and unspecified disc disorder - 723.0

Spinal stenosis in cervical region - 723.2–723.5

Other disorders of cervical region

Group D Diagnoses Covered for: 721.3

Lumbosacral spondylosis without myelopathy - 721.41–721.42

Lumbosacral spondylosis with myelopathy - 721.7

Traumatic spondylopathy - 722.0

Displacement of cervical intervertebral disc without myelopathy - 722.10–722.11

Displacement of thoracic or lumbar intervertebral disc without myelopathy - 722.4

Degeneration of cervical intervertebral disc - 722.51–722.52

Degeneration of thoracic or lumbar intervertebral disc - 722.6

Degeneration of intervertebral disc site unspecified - 722.81–722.83

Postlaminectomy syndrome - 724.01–724.03

Spinal stenosis, other than cervical - 724.3–724.4

Other and unspecified disorders of back - 724.6

Disorders of sacrum, ankylosis - 738.4

Acquired spondylolisthesis - 756.11–756.12

Anomalies of spine - 839.01–839.08

Other, multiple and ill-defined dislocations, cervical vertebra, - 839.20–839.21

Other, multiple and ill-defined dislocations, thoracic and lumbar vertebra, closed - 839.41–839.42

Other, multiple and ill-defined dislocations, other vertebra, closed - 953.0–953.4

Injury to nerve roots and spinal plexus

Note: Providers should continue to submit ICD-9-CM diagnosis codes without decimals on their claim forms and electronic claims.

Documentation Requirements

Documentation supporting medical necessity should be legible, maintained in the patient’s medical record and made available to Medicare upon request. Please see Medicare Benefit Manual sections referenced above for national documentation requirements for Medicare payment of chiropractic services.

Chiropractic billing important questions

FREQUENTLY ASKED QUESTIONS

Question: What is the difference between the GP and GY modifiers? Do we use GP, GY and GA for physical therapy charges?

Answer: Yes, it is possible that physical therapy services could be billed with all three modifiers. (Remember that the patient does not have to sign an Advance Beneficiary Notice of Noncoverage (ABN) to be held financially responsible.)

* GP: Services delivered under an outpatient physical therapy plan of care.

Chiropractors billing for physical therapy services (CPT codes 97001–97799 and HCPCS code G0283) must bill with the appropriate modifier. Even though physical therapy billed by a chiropractor is a program exclusion, if one of the above modifiers is omitted from any of the codes referenced, the service will be rejected. This rejection would require the claim to be corrected and resubmitted.

* GY: Used to indicate an item or service statutorily excluded or it does not meet the definition of any Medicare benefit.

This modifier can be used when billing for a non-covered service to later bill to the patient’s secondary insurance for consideration (e.g., X-rays or physical therapy).

* GA: Used to indicate that an ABN is on file.

A copy of the ABN does not have to be submitted with the claim but must be made available upon request.

Question: Do we need an ABN on file for physical therapy, X-rays and exams if we are not billing Medicare? Or is it voluntary?

Answer: The only Medicare Part B benefit for chiropractors is the spinal manipulation. All services other than spinal manipulation, such as X-rays, office visits, physical therapy services, supplies or extra-spinal manipulations, are considered excluded services and are not a Medicare Part B benefit. These types of excluded services are never covered and are always the patient’s financial responsibility. Therefore, the ABN is not required to hold the patient financially responsible.

Question: Do we have to bill Medicare for physical therapy, X-rays and exams even though we know Medicare will not cover them?

Answer: These types of services do not have to be billed to Medicare because they are program exclusions. In some cases, the patient might request that you bill all services provided to Medicare for the purpose of supplemental insurance or for their records, and in this case, they should be billed.

Question: Is there a limit for the number of modifiers used?

Answer: Paper claim submitters only have the ability to bill four modifiers. However, electronic billers sometimes have the capability to bill up to eight modifiers.

Difference between new and established patients

New and Established Patients

To recognize the different levels of service between a patient that has not received care in a practice (and therefore needs more explanations regarding the operation of the practice) and an established patient (who is aware of the practice’s routines), there are different coding categories.  

New Patient – A new patient is a patient who has not received any professional services from the provider, or another provider of the same specialty, who belongs to the same group practice, within the past three years. 

observation CPT code 99217 - 99220, 99234 - 99236 - How to bill

Hospital Observation Services 99217-99220 and 99234-99236

Placement in observation status requires an order from a provider with admitting privileges.  Patients are in observation to determine whether the patient should be admitted to the hospital, transferred to another facility, or sent home.

When there is a three-day observation period, the middle day is coded with an established outpatient visit code, 99211-99215 based on the documentation.

The following services are not covered as outpatient observation services:

•    Observation services that exceed 24 hours unless an exception is deemed necessary following a medical necessity review.  

•    Services that are not reasonable or necessary for the diagnosis or treatment of the patient but are provided for the convenience of the patient, his or her family, or a physician/provider (e.g., following an uncomplicated treatment or procedure; physician/provider busy when patient is physically ready for discharge; patient awaiting placement in a long-term care facility).

•    Inpatient services.

•    Services associated with ambulatory procedure visits.

•    Routine preparation services furnished prior to the testing and recovery afterwards (e.g., patients undergoing diagnostic testing in a hospital outpatient department).

•    Observation concurrent with treatments such as chemotherapy.

•    Services for postoperative monitoring.

•    Any substitution of an outpatient observation service for a medically appropriate inpatient admission.

•    Services that were ordered as inpatient services by the admitting physician/provider but reported as outpatient observation services by the hospital.

•    Standing orders for observation following outpatient services.

•    Discharges to outpatient observation status after an inpatient hospital admission.

When a patient is admitted from observation status, the ADM record for the observation care should be closed out with a disposition type of “admitted.”  

When a patient is referred from observation to an ambulatory procedure unit (APU) or another MTF, the ADM record for the observation care is closed out with disposition type of “immediate referral.”  

E&M codes will be used to document the length and acuity of observation care services in ADM. Observation E&M codes relate to the number of calendar days (dates) the patient spends in observation status and the acuity of the stay.

Observation new cpt code - 99218, 99219, 99220, 99224, 99225, 99217

Initial Observation care:

99218  Initial observation care, per day, for the evaluation and management of a patient which requires these 3 key components: A detailed or comprehensive history; A detailed or comprehensive examination; and Medical decision making that is straightforward or of low complexity. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the problem(s) requiring admission to "observation status" are of low severity.

99219  Initial observation care, per day, for the evaluation and management of a patient, which requires these 3 key components: A comprehensive history; A comprehensive examination; and Medical decision making of moderate complexity. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the problem(s) requiring admission to "observation status" are of moderate severity.

99220  Initial observation care, per day, for the evaluation and management of a patient, which requires these 3 key components: A comprehensive history; A comprehensive examination; and Medical decision making of high complexity. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the problem(s) requiring admission to "observation status" are of high severity.

Subsequent Observation care: New codes effective from Jan 1, 2011

99224 - Subsequent observation care, per day, for the evaluation and management of a patient, which requires at least 2 of these 3 key components: Problem focused interval history; Problem focused examination; Medical decision making that is straightforward or of low complexity. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the patient is stable, recovering, or improving. Physicians typically spend 15 minutes at the bedside and on the patient’s hospital floor or unit.

99225 - Subsequent observation care, per day, for the evaluation and management of a patient, which requires at least 2 of these 3 key components: An expanded problem focused interval history; An expanded problem focused examination; 

Medical decision making of moderate complexity. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the patient is responding inadequately to therapy or has developed a minor complication. Physicians typically spend 25 minutes at the bedside and on the patient’s hospital floor or unit

99226 - Subsequent observation care, per day, for the evaluation and management of a patient, which requires at least 2 of these 3 key components: A detailed interval history; A detailed examination; 

Medical decision making of high complexity. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the patient is unstable or has developed a significant complication or a significant new problem. Physicians typically spend 35 minutes at the bedside and on the patient’s hospital floor or unit.

Observation discharge:

99217  Observation care discharge day management (This code is to be utilized by the physician to report all services provided to a patient on discharge from "observation status" if the discharge is on other than the initial date of "observation status." To report services to a patient designated as "observation status" or "inpatient status" and discharged on the same date, use the codes for Observation or Inpatient Care Services [including Admission and Discharge Services, 99234-99236 as appropriate.])

Hospital Observation care CPT code 99234 - 99236

Documentation Requirements for Billing Hospital Observation care CPT code 99234 - 99236 Observation or Inpatient Care Services (Including Admission and Discharge Services (Codes 99234–99236))

The physician should satisfy the E/M documentation guidelines for furnishing observation care or inpatient hospital care. In addition to meeting the  documentation requirements for history, examination and medical decision-making, documentation in the medical record shall include:

* Documentation noting the stay for observation care or inpatient hospital care involves eight hours, but less than 24 hours.

* Documentation identifying the billing physician was present and personally performed the services.

* Documentation identifying the order for observation services, progress notes and discharge notes were written by the billing physician.

In the rare circumstance when a patient receives observation services for more than two calendar dates, the physician should bill a visit furnished before the discharge date using the outpatient/office visit codes. The physician may not use the subsequent hospital care codes since the patient is not an inpatient of the hospital.

Admission to Inpatient Status Following Observation Care

* If the same physician who ordered hospital outpatient observation services also admits the patient to inpatient status before the end of the date on which the patient began receiving hospital outpatient observation services, Medicare should pay only an initial hospital visit for the E/M services provided on that date.

* Medicare payment for the initial hospital visit includes all services provided to the patient on the date of admission by that physician, regardless of the site of service.

* The physician may not bill an initial observation care code for services on the date he admits the patient to inpatient status.

* If the patient is admitted to inpatient status from hospital outpatient observation care subsequent to the date of initiation of observation services, the physician must bill an initial hospital visit for the services provided on that date.

The physician may not bill the hospital observation discharge management code (99217) or an outpatient/office visit for the care provided while the patient received hospital outpatient observation services on the date of admission to inpatient status.

Hospital Observation Services During Global Surgical Period

The global surgical fee includes payment for hospital observation (codes 99217, 99218, 99219, 99220, 99234, 99235 and 99236) services unless the criteria for use of modifiers 24, 25 or 57 are met. These services are paid in addition to the global surgical fee only if both of the following requirements are met:

* The hospital observation service meets the criteria needed to justify billing it with modifiers 24, 25 or 57 (decision for major surgery).

* The hospital observation service furnished by the surgeon meets all the criteria for the hospital observation code billed.

Initial Observation Care Codes 99218–99220

Who May Bill Initial Observation Care

Observation care is a well-defined set of specific, clinically appropriate services, which include ongoing short-term treatment, assessment and reassessment, that are furnished while a decision is being made regarding whether patients will require further treatment as hospital inpatients or if they are able to be discharged from the hospital.

Observation services are commonly ordered for patients who present to the emergency department and who then require a significant period of treatment or monitoring to make a decision concerning their admission or discharge.

In only rare and exceptional cases do reasonable and necessary outpatient observation services span more than 48 hours. In the majority of cases, the decision whether to discharge a patient from the hospital following resolution of the reason for the observation care or to admit the patient as an inpatient can be made in fewer than 48 hours, usually in fewer than 24 hours.

* Payment may only be made to the physician who ordered hospital outpatient observation services and was responsible for the patient during his observation care.

* A physician who does not have inpatient admitting privileges but who is authorized to furnish hospital outpatient observation services may bill these codes.

* There must be a medical observation record for the patient that contains dated and timed physician’s orders regarding the observation services the patient is to receive, nursing notes and progress notes prepared by the physician while the patient received observation services. This record must be in addition to any record prepared as a result of an emergency department or outpatient clinic encounter.

* Payment for an initial observation care code is for all the care rendered by the ordering physician on the date the patient’s observation services began. All other physicians who furnish consultations or additional evaluations or services while the patient is receiving hospital outpatient observation services must bill the appropriate outpatient service codes.

Example: 

If an internist orders observation services and asks another physician to additionally evaluate the patient, only the internist may bill the initial observation care code. The other physician who evaluates the patient must bill the new or established office or other outpatient visit codes as appropriate.

Physician Billing for Observation Care Following Initiation of Observation Services

When a patient receives observation care for less than eight hours on the same  calendar date, the initial observation care from CPT code range 99218–99220should be reported by the physician. The observation care discharge service, CPT code 99217, should not be reported for this scenario.

When a patient is admitted for observation care and then is discharged on a different calendar date, the physician shall report initial observation care from CPT code range 99218–99220 and CPT observation care discharge CPT code 99217.

When a patient receives observation care for a minimum of eight hours but less than 24 hours and is discharged on the same calendar date, observation or inpatient care services (including admission and discharge services) from CPT code range 99234–99236 should be reported. The observation discharge, CPT code 99217, cannot also be reported for this scenario.

Usage of Modifier 25 - when to use and tips

When should CPT modifier -25 be used?

Common Procedural Terminology (CPT) modifier -25 identifies a significant, separately identifiable evaluation and management (E/M) service. It should be used when the E/M service is above and beyond the usual pre- and post- operative work on a procedure with a global fee period performed on the same day as the E/M service

• The Centers for Medicare & Medicaid Services (CMS) has clarified the documentation requirements and policy requirements for the use of CPT modifier -25 used with E/M services. Please refer to the manual attachment to CR5025, The Medicare Claims Processing Manual, Publication 100-04, Chapter 12, Section 30.6.6, for revisions regarding the use of CPT modifier -25.

• Physicians and qualified nonphysician practitioners (NPP) should use CPT modifier -25 to designate a significant, separately identifiable E/M service provided by the same physician/qualified NPP to the same patient on the same day as another procedure or other service with a global fee period.

• Common Procedural Terminology (CPT) modifier -25 identifies a significant, separately identifiable evaluation and management (E/M) service. It should be used when the E/M service is above and beyond the usual pre- and post- operative work of a procedure with a global fee period performed on the same day as the E/M service.

• Different diagnoses are not required for reporting the E/M service on the same date as the procedure or other service with a global fee period. Modifier -25 is added to the E/M code on the claim.

• Both the medically necessary E/M service and the procedure must be appropriately and sufficiently documented by the physician or qualified NPP in the patient’s medical record to support the need for Modifier -25 on the claim for these services, even though the documentation is not required to be submitted with the claim.

• Your carrier will not retract payment for claims already paid or retroactively pay claims processed prior to the implementation of CR5025. But, they will adjust claims brought to their attention.

• Carriers will not pay for an E/M service reported with a procedure having a global fee period unless CPT modifier -25 is appended to the E/M service to designate it as a significant and separately identifiable E/M service from the procedure. Such payment will be denied with the following messages:

Billing modifier 22 - Usage and coding tips

Modifier 22 INCREASED PROCEDURAL SERVICES

When the work required to provide a service is substantially greater than typically required, it may be identified by adding modifier 22 to the usual procedure code.

Documentation must support the substantial additional work and the reason for the additional work (i.e., increased intensity, time, technical difficulty of procedure, severity of patient's condition, physical and mental effort required). Note: This modifier should not be appended to an E/M service.

Using the Modifier Correctly

• Modifier 22 is appended to the basic CPT® procedure code when the service(s) provided is greater than usually required for the listed procedure. Use of modifier 22 allows the claim to undergo individual consideration.

• Modifier 22 is used to identify an increment of work that is infrequently encountered with a particular procedure and is not described by another code.

• Modifier 22 is generally not appended to a radiology code. If a rare circumstance does occur, submit detailed documentation with a cover letter from the radiologist or other provider.

• The frequent reporting of modifier 22 has prompted many payers to simply ignore it.

• Modifier 22 is used with computerized tomography (CT) numbers when additional slices are required or a more detailed examination is necessary. However, this is subject to payer discretion. Many payers will not allow additional reimbursement for additional CT slices.

Incorrect Use of the Modifier

• Appending this modifier to a radiology code without justification in the medical record documenting an unusual occurrence. Because of its overuse, many payers do not acknowledge this modifier.

• Using this modifier on a routine basis; to do so will cause scrutiny of submitted claims and may result in an audit.

• Using modifier 22 to indicate that the radiology procedure was performed by a specialist; specialty designation does not warrant use of modifier 22.

• Using modifier 22 when more x-rays views are taken than actually specified by the CPT code description. This is incorrect, especially when the code descriptor reads “complete” (e.g., 70130, 70321, 73110, etc.). Complete means any number of views taken of the body site.

Coding Tips

• Using modifier 22 identifies the service as one that requires individual consideration and manual review.

• Overuse of modifier 22 could trigger a payer audit. Payers monitor the use of this modifier very carefully. Modifier 22 should be used only when sufficient documentation is present in the medical record.

• A Medicare claim submitted with modifier 22 is forwarded to the payer medical review staff for review and pricing. With sufficient documentation of medical necessity, increased payment may result.

Modifier 22 (Unusual Procedural Services)

Tufts Health Plan requires documentation when claims are submitted with modifier 22 (unusual procedural services). Claims submitted without additional documentation are not considered for additional compensation. Clinical documentation must indicate one of the following:

** Excessive blood loss for the particular procedure performed

** Extensive, well-documented adhesions present with an abdominal surgery and requiring minimum of 45 minutes to lyse

** Presence of an excessively large surgical specimen (tumor)

** Trauma so extensive that the particular procedure and complication is not billed as separate and distinct procedures themselves

** Other pathologies, tumors and malformations that increase the complexity of the procedure

** Extended anesthesia is identified (anesthesia record must be submitted)

Do not submit modifier 22 if you are reporting any of the following:

** Increased complexity due to a surgeon’s choice of approach

** Describing a re-operation

** Describing a weight reduction surgery

** Describing the use of robotic assistance

** An unspecified procedure code

Usage of Modifier 25

Most used Modifier 25 - is Significant, Separately Identifiable Evaluation andManagement Service by the Same Physician on the Same Day of theProcedure or Other Service.

Key Points to Remember:

When using this modifier, Medical Documentation is vital and essential to support medical necessity. This must be well-documented on the patient's medical record.

You are using Modifier -25 because you are stating that the Evaluation and Management Service is separate from that of the procedure performed on the same day.

Append this modifier if and only if it is a medical necessity and is a separately identifiable E/M service of that with the procedure done on the same day.

Sample Encounter 1:

The patient came in to the office with a chief complaint of entire body ache. She also present with an abscessed toe nail which she claims started after she cut her toe nails using a toe-nail cutter 2 days ago. The physician then added the incision and drainage procedure performed on the abscessed toe nail.

Codes:

99212-25

18060

Sample Encounter 2:

The patient came in to the office for her scheduled 2nd therapeutic knee injection. On the same day, she presented herself as complaining with neck pain that has been bothering her sleep for the past 3 days. The physician then added a separate E/M service. 

Codes:

99213-25

20610

CPT modifiers 25 question - where and when to use

If you perform a preventive care service and an immunization simultaneously, would you apply a modifier? Example: Providing an Annual Wellness Visit (AWV) and a preventive vaccination.

2A: The AWV is not an E/M service; therefore, E/M modifiers do not apply. However, you should ensure documentation is present in the medical record to support the separate immunization.

 If a new patient presents to a practice and ends up having a joint injection during that same visit, is the E/M billable? Would I use the 25 modifier?

3A: If the patient is not coming specifically for a joint injection, then 'No,' the modifier is not needed since the patient is being seen as a new patient. The modifier 25 is not needed with an initial E/M service code.

However, if the patient is established and presented for an E/M service only, and the joint injection was performed as a result of the E/M, then 'Yes,' you can bill the E/M and apply modifier 25 as long as documentation can be provided showing the medical necessity for the services

If we provide a preventive immunization (e.g., pneumococcal vaccination), should we use modifier 25?

4A: If an established patient is not coming in specifically for the preventive immunization, then 'Yes' you could apply modifier 25 to the E/M service as long as documentation can be provided showing the medical necessity for the services.

 If an initial consultation and/or follow-up office visit requires a chest X-ray, pulmonary function test (PFT) or 6-minute walk (stress test) for the purposes of evaluation, would the E/M service require modifier 25?

5A. Again, if the rationale for why the patient is there is the X-ray, PFT or stress test, then a separate E/M wouldn't be payable. However, if the patient is there for an initial consultation and the X-ray or PFT is then ordered and performed, then modifier 25 may be billed as long as documentation can be provided showing the medical necessity for the services.

 Is there a penalty when modifier 25 is inappropriately applied to a new patient visit code?

6A: Currently, there is no editing to prevent the modifier 25 from being billed with initial visits as previous guidelines did require the modifier. However, since the modifier is not required, future editing enhancements could cause the claim to be returned as unprocessable for an invalid modifier.

 If the patient presents with joint pain and has a joint injection on the same day, can we bill for both the office visit and the injection or would the documentation requirements have to be met?

7A: If the patient is new and is not coming specifically for a joint injection, then 'No,' the modifier is not needed. Since the patient is being seen as a new patient, the modifier 25 is not needed with an initial E/M service code.

However, if the patient is established and presented for the E/M service only and the joint injection was performed as a result of the E/M, then 'Yes,' you can bill the E/M and apply modifier 25 as long as documentation can be provided showing the medical necessity for the services.

When an inpatient is in a critical care unit and the physician inserts a Swan-Ganz during the visit, do we append a modifier 25 to the Current Procedural Terminology® (CPT®) code 99291?

9A. Regarding critical care services, if the services are separately identifiable from why the patient is in the hospital, then 'Yes,' the code can be billed with modifier 25 as long as documentation can be provided showing the medical necessity for the services.

Services such as endotracheal intubation (CPT code 31500) and the insertion and placement of a flow directed catheter e.g., Swan-Ganz (CPT code 93503) are not bundled into critical care codes. Therefore, separate payment may be made for critical care in addition to these services if the critical care was a significant, separately identifiable service and it was reported with modifier 25.

However, if the critical care is being provided due to the rationale for why they are in the hospital, then everything would be rolled up under the hospital billing.

How significant must the change in treatment plan be? 

Common scenario: Patient with known arthritis being managed conservatively presents complaining of increasing pain and the physician does a steroid injection to knee.

10A. If the patient has been on a specific plan regiment for a while (ex.: 3- to 6-months) and the plan changes significantly (arthritis gets extremely exacerbated or detrimentally worse), you can bill the modifier 25 as long as documentation can be provided showing the medical necessity for the services.

 A patient comes in for a post-operative visit within the global days for sinus surgery and has complaints of sinus pressure and is sneezing. Would this be considered related or unrelated? Does this allow for an E/M visit with a modifier 24?

11A. If the physician determines the pressure and sneezing is unrelated to the surgery and provides the rationale in the records, they can bill for an E/M with a modifier 24 as long as documentation can be provided showing the medical necessity for the services. Documentation will likely be requested.

If we provide an outpatient surgery on a patient (ex: 90-day global period) and admit the patient after surgery, can we bill for the admission, subsequent hospital days, and the discharge?

12A. Depends on whether the admission is related to the surgery or not. Here are some examples of services not included in the global period:

• Services of other physicians except where the surgeon and the other physician(s) agree on the transfer of care.

• Visits or hospitalization unrelated to the diagnosis for which the surgical procedure is performed, unless the visits occur due to complications of the surgery.

• Treatment for the underlying condition or an added course of treatment which is not part of normal recovery from surgery

Use of modifier 24 will require documentation to be reviewed. The separate services may be billed as long as documentation can be provided showing the distinction and medical necessity for the services