CODING Q&A

Audits Are on the Rise for Modifier 25, So Get It Right

SUZANNE L. CORCORAN, COE

The use of modifier 25 to claim reimbursement for an exam on the day of a minor procedure has increased dramatically in recent years. Postpayment audits of modifier 25 have increased, too.

Q. What does modifier 25 mean?

A. CPT defines modifier 25 as “Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure.”¹ Using modifier 25 indicates that the patient’s condition required an exam beyond the usual preoperative and postoperative care associated with the procedure performed. CPT adds, “This modifier is not used to report an E/M service that resulted in a decision to perform surgery.” Under Medicare rules, the decision to proceed with major surgery constitutes a billable exam (with modifier -57); this is not the case for minor procedures (ie, those with 0 or 10-day global periods).

The American Academy of Ophthalmology adds, “A frequently asked question is: Isn’t modifier -25 associated with minor procedures in the same way that modifier -57 is associated with a decision for a major surgery? The answer is no. Modifier -25 does not indicate it is the visit to determine the need for a minor surgery.” AAO specifically states, “If the need for the intravitreal injection has been established at an earlier visit and the patient is in the office solely to be injected, an E&M or Eye code service should not be billed.”²

CMS instructs, “... 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.”³

Examples of “significant, separately identifiable” exams include:

• a medically necessary exam of the eye that is not injected,

• an exam of one or both eyes for a condition unrelated to the intravitreal injection.

Q. Isn’t an eye exam essential prior to the intravitreal injection? How are physicians paid for it?

A. Within Medicare’s global surgery package concept, the Relative Value Units (RVUs) assigned to the minor procedure include preoperative and postoperative exams. Billing separately for an eye exam on the day of a minor procedure is duplicative if it is related to the minor procedure. Only if the eye exam has nothing to do with the same-day minor procedure is separate payment possibly justified. So, if every intravitreal injection is billed with an eye exam, then Medicare would likely question the merit of the E/M or eye code.

Q. Will the use of modifier 25 attract attention from Medicare or other payers?

A. Excessive use of this modifier may garner unwanted attention. A report⁴ by the Office of Inspector General (OIG) indicated that 35% of 2002 claims with modifier 25 did not meet program requirements; we believe this is still true and may have gotten worse. As a result, Medicare contractors and other third-party payers are working to reduce inappropriate claim submission with modifier 25.

Q. Are different diagnoses required?

A. No. The CPT definition of modifier 25 specifically states, “… different diagnoses are not required for reporting of the E/M services on the same date.” To appreciate this instruction, you should understand that it does not diminish or contradict the prior instruction with respect to the purpose of the visit. For example, your patient has exudative macular degeneration (ICD-9: 362.52, ICD-10: H35.32) in both eyes. During today’s exam, you evaluate both eyes, but inject only the left eye.

There is just one diagnosis — it applies to both eyes. Modifier 25 applies, but for the exam of the eye that was not injected.

Q. How often should we use modifier 25?

A. Within the Part B Medicare program, 11% of all eye exams performed by ophthalmologists (all subspecialties) are associated with modifier 25. In the subgroup of retina specialists for CY 2013, 1.3 million intravitreal injections were performed on Medicare beneficiaries. Based on chart reviews performed by Corcoran’s certified professional medical auditors, about 25% to 33% of all intravitreal injections were associated with an exam for an unrelated reason that justified modifier 25.

Q. Does the use of modifier 25 affect the value ascribed to the exam?

A. No. Use of modifier 25 makes full reimbursement of the office visit and the minor procedure possible. Without it, the exam would be considered preoperative and not paid at all.

Q. What is the best way to document a minor procedure?

A. The exam and minor surgery may appear on the same page in the medical record, but we don’t recommend it. We suggest a separate operative report for the surgery. It should contain the indications for the procedure, a description of the procedure, and discharge instructions. A Minor Procedure Treatment form is available for download at no charge on our website.

A clearly documented consent for the procedure should also be documented, either written or verbal. RP

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