Use and Abuse of Modifier -25

Are you using modifier -25 correctly in submitting reimbursement forms to CMS for intravitreal injection?

KEVIN J. CORCORAN, COE, CPC, FNAO

In 2007, the most recent year for which Medicare data is available, 6.5% of all Medicare claims for office visits performed by ophthalmologists included modifier -25. That percentage hasn't changed since 2001 — it's constant. The Office of Inspector General (OIG) thinks that may be too high. A November 2005 report¹ released by the OIG indicated that 35% of 2002 claims with modifier -25 did not meet program requirements. They recommended that CMS work with Medicare administrative contractors (MACs) to reduce inappropriate claim submissions with modifier 25.

In its 2009 work plan, the OIG intends to scrutinize claims for evaluation and management (E/M) services within the global surgical period, including those that use modifier -25. In this article, we'll take a fresh look at modifier -25 and its application, particularly in the context of intravitreal injections.

DEFINITION OF MODIFIER -25

The current edition of the CPT manual defines modifier -25 as: “Significant, Separately Identifiable Evaluation and Management Service by the Same Physician on the Same Day of the Procedure or Other Service: It may be necessary to indicate that on the day a procedure or service identified by a CPT code was performed, the patient's condition required a significant, separately identified 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. A significant, separately identifiable E/M service is defined or substantiated by documentation that satisfies the relevant criteria for the respective E/M service to be reported … The E/M service may be prompted by the symptom or condition for which the procedure and/or service was provided. As such, different diagnoses are not required for reporting of the E/M service. Note: This modifier is not used to report an E/M service that resulted in a decision to perform surgery. See modifier '57.' For significant, separately identifiable non-E/M services, see modifier '59.'”

What makes an office visit “separately identifiable”? According to Medicare, this requirement is met when the office visit or consultation is substantial, distinct and unique, and it stands alone. It distinguishes itself from the minor procedure because it extends beyond the typical preoperative work. This may entail examination of other organ systems, examination of the opposite side of the body from the affected area, evaluation of a constellation of symptoms that suggest numerous problems, or other concurrent treatments besides the minor procedure.

The Medicare Claims Processing Manual (Chapter 12, §40.1 C) states, “Visits by the same physician on the same day as a minor surgery or endoscopy are included in the payment for the procedure, unless a significant, separately identifiable service is also performed. For example, a visit on the same day could be properly billed in addition to suturing a scalp wound if a full neurological examination is made for a patient with head trauma. Billing for a visit would not be appropriate if the physician only identified the need for sutures and confirmed allergy and immunization status.”

MINOR SURGERIES AND MODIFIER -25

The Medicare Claims Processing Manual contains billing requirements for major and minor surgical procedures. Minor surgeries have a zero or 10-day postoperative period. An intravitreal injection (67028) has zero postop days, so it is properly considered a minor procedure.

The global surgery package concept applies to minor procedures and includes:

► Preoperative visit on the day of surgery
► Postoperative visits related to recovery
► Some supplies, such as a surgical tray

Services not included in the global surgery package are:

► Same-day examination when a separately identifiable service is performed
► Diagnostic tests and procedures, including diagnostic radiological procedures
► Postop visits unrelated to the diagnosis for which the surgical procedure is performed
► Clearly distinct surgical procedures that are not reoperations or treatment for complications

The Medicare Claims Processing Manual (Chapter 12, §40.1 B) states, “Services Not Included in the Global Surgical Package — The initial consultation or evaluation of the problem by the surgeon to determine the need for surgery. Please note that this policy only applies to major surgical procedures. The initial evaluation is always included in the allowance for a minor surgical procedure.”

Our experience is similar to OIG's; many office visits don't meet the requirements to use modifier -25. The same-day exam is usually preoperative work. The Medicare Claims Processing Manual (Chapter 12, Section 40.2.A.4), E/M Service Resulting in the Initial Decision to Perform Surgery states, “… where the decision to perform the minor procedure is typically done immediately before the service, it is considered a routine preoperative service and a visit or consultation is not billed in addition to the procedure.” An office visit to address a different problem than the one leading to the minor procedure will be the exception that justifies modifier -25.

NEW PATIENTS

Some MACs publish guidelines that say the E/M services required for a new patient prior to the performance of a minor procedure would constitute a separately identifiable service. CMS has not published a national directive on this issue, so look to your local MAC for confirmation of this concept.

ICD-9 CODING

A controversy surrounds coding for symptoms, such as “blurry vision” (368.8), in addition to the ultimate diagnosis that describes the etiology of the symptom (eg, AMD) as a mechanism for justifying modifier -25. The introduction to ICD-9-CM states, “Codes that describe symptoms as opposed to diagnoses are acceptable if this is the highest level of certainty documented by the physician.” In light of this instruction, symptoms should be coded and used on the claim form if the physician cannot explain them and the cause is unknown, but that's a rare occurrence. In the common case where a diagnosis is rendered (eg, AMD) that comports with the symptoms (eg, blurry vision), then the ICD-9 code for the disease entity suffices and the symptoms are not coded, too. Modifier -25 would not be justified.

EXAMPLES

The following case studies depict separately identifiable E/M services from the minor surgery procedures.

Case Study With a Solitary Diagnosis

Your patient has exudative AMD, OU. An intravitreal injection of an anti-VEGF agent is planned for today, OD. A dilated fundus exam of both eyes will be performed along with OCT, OU.

The separately identifiable exam requirement is subtly met because the exam of the left eye is distinct from the exam and procedure performed on the right eye. Both services, office visit and intravitreal injection, utilize the same diagnosis code (362.52). As noted earlier, CPT states, “…different diagnoses are not required for reporting of the E/M service,” but different problems are necessary as shown here by two eyes.

Case Study With Multiple Related Diagnoses

Your patient with hypertension, cholesterolemia and a long-time history of heavy smoking is being followed regularly for high concentrations of drusen, OU. During today's exam, the patient also complains of reduced ability to read, even in good lighting. Your examination identifies: AMD, OU and hypertensive retinopathy with the appearance of some occlusion, OU Fluorescein angiography and OCT demonstrate exudative AMD, OS and nonexudative AMD, OD. You recommend immediate intravitreal injection of an anti-VEGF agent OS and another follow-up visit is scheduled in four weeks.

The chart notes documented the evaluation of the posterior segment of the eye for more than one disease, not solely for AMD. The related vascular diseases are particularly noteworthy and likely contributory. The reason for the office visit extends above and beyond the usual preoperative service. The exam is filed with modifier -25; intravitreal injection (67028-LT) is also included on the claim. The primary ICD-9 code for the exam (362.51, dry AMD) is different from the code for intravitreal injection (362.52, wet AMD). A subordinate ICD-9 code for the exam is 362.11 (hypertensive retinopathy), but claims processing only looks to the primary codes.

Case Study With Multiple Unrelated Diagnoses

Your patient presents for a follow-up of exudative AMD and a repeat injection of an anti-VEGF agent, OS. She continues to have difficulty with poor vision and complains of new floaters, OD. Your examination identifies: macular puckering, OS, vitreous floaters, OD, and exudative AMD, OU. An intravitreal injection is administered as planned, OS.

The exam code uses modifier -25 with a diagnosis of macular puckering (362.56) and vitreous floaters (379.24). The intravitreal injection (67028-LT) is filed with a diagnosis of exudative AMD (362.52).

The following case studies provide examples when the exam would not be considered a separately identifiable service and not billed.

Case Study Without Separately Identifiable Exam

Your established patient presents today for a scheduled intravitreal injection of an anti-VEGF agent in her left eye. Examination and OCT of that eye demonstrate progressive exudative AMD, OS. The right eye was not examined today; it was evaluated four weeks ago.

The need for the minor procedure was previously determined. Today's exam is considered preop. It only identified one problem; therefore, it is not a separately identifiable service.

Case Study Without Separately Identifiable Exam

Your patient was last seen six weeks ago and received her third intravitreal injection, OS. Examination today will determine whether a fourth injection is needed now or can be postponed. OCT of that eye demonstrates progressive exudative AMD. You proceed with the injection based on these findings. Your examination of the fellow eye is unremarkable and noncontributory.

The decision for minor surgery does not, in itself, support the use of modifier -25.

KEY POINTS

Keep in mind these essential pointers:

► Modifier -25 should not be associated with every minor procedure. It is the exception, not the rule. Monitor utilization of this modifier.
► Modifier -25 is appended to E/M or eye codes, not to a minor procedure code.
► The office visit addresses another problem than the one for which the minor procedure is performed, not necessarily a different diagnosis. It represents more than the decision for surgery. It extends above and beyond preoperative care. RP

REFERENCE

1. Department of Health and Human Services, Office of Inspector General. Use of Modifier 25. OEI-07-03-00470. November 2005. http://oig.hhs.gov/oei/reports/oei-07-03-00470.pdf. Accessed September 24, 2009.