Separate, But Not Distinct: The Appropriate Use Of Modifiers 25 And 59

(1)

Separate, But Not Distinct: The

Appropriate Use Of Modifiers

25 And 59

Sandy Giangreco, RHIT, CCS, CPC, CPC-H, CPC-I, PCS AHIMA Approved ICD-10-CM/PCS Trainer

Jenny Studdard, CPC, RCC, CPCO AHIMA Approved ICD-10-CM Trainer

Agenda

• What purpose do they serve

• What is the Global Surgical Package

• Separate & Distinct E/M Service

• Appropriate Use of Modifier 25

• What is National Correct Coding Initiative

(NCCI)

• Separate & Distinct Procedures

• Appropriate Use of Modifier 59

What is the Purpose of a Modifier

• An integral part of the structure of the CPT

code set

• Indicates that a service of procedure that was

performed has in some way been altered

– The code definition has not changed

• Enable professionals to respond effectively to

payment policy requirements established by

other entities

(2)

Usage of Modifiers

• Reporting only the professional component

• Report a service mandated by a 3

rd

_party

payer

• Proc performed bilaterally

• Report that multiple proc were performed at

same session by same prov

• Report a portion of the service or proc was

reduced or eliminated at physicians discretion

• Report assistant surgeon services

Global Surgical Package

• Reimbursement for the surgical procedure

includes some related E&M services

• Specific E&M services included vary

depending on whether the procedure is

defined as a major surgical procedure, minor

surgical procedure or non-surgical

Global Surgical Package

• All diagnostic/therapeutic procedures include:

– Obtaining limited pertinent history – Confirming reason for the procedure

– Establishing presence of allergies / comorbidities that may impact procedure

– Obtaining informed consent – Review of medical record – Provision of follow-up instructions – Pre / post procedure patient care

(3)

Global Surgical Package

• Non-Surgical Procedures

– Procedures with no defined global period

– Have inherent pre-procedure, intra-procedure, and post-procedure work which should not be reported as an E&M service

– Only when a significant, separately identifiable service is rendered which involves taking a history, performing an exam, and making medical

decisions distinct from the procedure may an E&M be reported in addition to the procedure

Global Surgical Package

• Non-Surgical Procedures

– Catheter placements

– Fistulogram with catheter placement – Fine needle aspirations

– Declotting Central Venous Catheter – Intracranial angioplasty

Global Surgical Package

• Minor Surgical Procedures (0 or 10 day global)

– All include E&M on the same day

– Some include E&M for 10 days following the procedure

– Significant and separately identifiable E&M may be billed within the global period

• The decision to perform a minor surgical is included in the reimbursement for that procedure and should not be reported as a separate E&M

(4)

Global Surgical Package

• Minor Surgical Procedures (0 or 10 day global)

– Procedures with 0 day global period include:

• Needle biopsies

• Lower extremity revascularization • PICC line placement

– Procedures with a 10 day global period include:

• Insertion, replacement & removal of tunneled CVC • Placement of G-tube & J-tube

• Incision & drainage of abscess, hematoma, & soft tissue abscess subfacial

For Example

• Breast Biopsy w/Guidance = 0 days

For Example

• Neuro Embolization = 0 days

(5)

For Example

• Kyphoplasty = 10 days

Global Surgical Package

• Minor Surgical Procedure (0 or 10 day global)

– When ever a pre-procedure E&M is billed, the documentation should clearly indicate why the service was above and beyond routine pre-procedure evaluation

– E&M services that meet the significant, separately identifiable standard should be billed with modifier 25 on the E&M code

– E&M services unrelated to the procedure are billable and should include modifier 24 on the E&M code

Global Surgical Package

• Major Surgical Procedures (90 day global)

– Includes E&M services on the day before the procedure and for ninety (90) days following the procedure with the following exceptions:

• Decision to perform surgical procedure is separately billable. E&M should be filed with modifier 57 to indicate that the decision to perform surgery was made at that visit

• Visits unrelated to the diagnosis for which the procedure was performed are separately billable. E&M should be filed with modifier 24 to indicate unrelated E&M by same physician during post-op period

(6)

For Example

• Internal/External Biliary Drain = 90 Days

Global Surgical Package

• Major Surgical Procedures (90 day global)

– Endovascular repair of the aorta or iliac artery – Dialysis fistula/graft declotting

– Carotid stent placement – Biliary drainage

CAN I BILL A VISIT OR NOT . . .

(7)

Pre-Procedure Visits

• When can a pre-procedure visit be coded?

– In most instances, a pre-procedure visit should be charged only if the patient’s condition necessitates a significant pre-procedure evaluation. Third party payors do not typically consider it medically necessary for the radiologist to provide a separately billable E/M service prior to every procedure. This service, if it is medically

necessary and appropriately documented, should be billed as an office/outpatient visit (CPT®_codes 99201-99215).

Follow-up Visits

• During the global period

– Routine Follow-Up Visits: Routine follow-up visits within the global period are not separately billable. – Payment for these visits is included in the global

surgical payment. No charges should be submitted to third party payors for routine post-procedure visits during the global period.

Follow-up Visits

• During the global period

– Post-Procedure Complications:

• CPT®_{definition - The Surgery guidelines in the} CPT®_{manual state, “Complications, exacerbations,} recurrence, or the presence of other diseases or injuries requiring additional services should be separately reported.” Therefore, visits during the global period for complications of the procedure can be billed to non-Medicare payors unless prohibited by payor policy.

(8)

Follow-up Visits

• During the global period

– Post-Procedure Complications:

• Medicare definition - E/M services related to post-procedure complications are included in the global payment for the procedure. Therefore, E/M services related to post-procedure complications should not be billed to Medicare.

Follow-up Visits

• During the global period

– Other Visits: The global surgical package does not include visits for treatment of the patient’s underlying condition, or visits for unrelated conditions. (See Medicare Claims Processing Manual, Chapter 12, Section 40.1.B.) These services are separately billable.

Follow-up Visits

• After the global period

– Follow-up visits after the global period are separately billable. However, the services must be medically necessary and reasonable for the patient’s condition. If it is no longer medically necessary for a patient to be seen following the global period, the physician should not bill for any additional follow-up visits.

(9)

Bottom Line

• Can the Provider Report an EM Service?

– Was the evaluation provided by the physician/NPP – Was the evaluation above/beyond the level required for the

surgical procedure/imaging study

– Was the evaluation outside of the “global package” – Does the documentation include all three key components

• Are extensive conversations appropriately documented – Is there a mechanism in place to capture the charge – Is the organization/practice ready to manage the co-pays

and patient inquires

Modifier 25

• Significant, separately identifiable evaluation

and management service by the same

physician on the same day of the procedure or

other service

• Although the E/M service may be provided for

the same diagnosis as the procedure, the E/M

service must be “above and beyond” the usual

pre- and post-procedure service.

Modifier 25

• Examples

– The physician is asked to see an inpatient in consultation regarding intra-abdominal bleeding following blunt trauma. The physician performs a Level IV initial inpatient consultation (99254) and determines that the bleeding may be amenable to transcatheter embolization (37204). Diagnostic angiography and embolization are performed the same day.

– Report code 99254-25 in addition to the codes for the angiography and embolization

(10)

Modifier 25

• Examples

– The physician is asked to see a patient in consultation in the hospital outpatient department regarding an abnormal mammogram and breast ultrasound. The physician performs a Level III office/outpatient consultation (99243), followed by biopsy of the breast lesion (19102).

– Report code 99243-25 in addition to the codes for the breast biopsy.

The Highlighter Test

• Eliminate all the documentation that relates to

the procedure. The documentation that is left

must meet the criteria for the E/M service in

terms of history, examination, and medical

decision making.

• If it does not, only the procedure should be

charged.

WHAT ABOUT PROCEDURES?

(11)

What is NCCI

• The CMS developed the National Correct

Coding Initiative (NCCI) to promote national

correct coding methodologies and to control

improper coding leading to inappropriate

payment in Part B claims.

What is NCCI

• These coding policies were developed based

on coding conventions defined in the AMA's

CPT manual, national and local policies and

edits, coding guidelines developed by national

societies, analysis of standard medical and

surgical practices, and a review of current

coding practices.

Separate & Distinct Procedure

• NCCI edits define when two procedure HCPCS/CPT

codes may not be reported together except under special circumstances.

• Special circumstances include:

– Different session or patient encounter – Different procedure or surgery – Different site or organ system – Separate incision/excision

– Separate lesion (different size or site groups) – Separate injury (multiple trauma injuries)

(12)

Separate & Distinct Procedure

• Example of Separate & Distinct Procedures

– HCPCS/CPT coding manual instruction/guideline state obtaining tissue during another procedure is a routine component of such procedure and not a separately billable biopsy.

• 17000 – destruction all benign or premalignant lesions other than skin tags or cutaneous vascular proliferative lesions, first lesion • 11100 – biopsy of skin, subcutaneous tissue and/or mucous

membrane (including simple closure) unless otherwise listed; single lesion

– If the biopsy was performed on a separate anatomic site than the destruction, it would be considered a separate & distinct procedure.

Separate & Distinct Procedure

• Documentation is integral to supporting

accurate reimbursement for separate & distinct

procedures.

• The medical record must demonstrate that the

service is separate and distinct from other

services performed that day.

Separate & Distinct Procedure

• Use the following 3 questions to determine whether a

service is considered part of the comprehensive procedure.

1. Does the service represent the standard of care in accomplishing the overall procedure?

2. Is the service necessary to successfully accomplish the comprehensive procedure? In other words, if you don’t perform the service, will the success of the procedure be compromised?

3. Does the service represent a separately identifiable procedure unrelated to the comprehensive procedure planned?

(13)

Modifier 59

• Indicates that a procedure is distinct, or

independent from, other services performed

on the same day

• Designates that an ordinarily bundled code

represents a service performed on a different

anatomic site or at a different session

• Documentation must support the separate

nature of the procedures

Modifier 59

• No other modifier is more appropriate

– e.g., 58, 78, 79, RT, LT – HCPCS anatomical modifiers

• Regular payment policies apply

– e.g., multiple procedure reductions

• Medicare uses the National Correct Coding

Initiative

• Other payers may use other products

– e.g., ClaimCheck, CodeCorrect

Modifier 59

• When the procedures performed meet the

separate and distinct standard as defined,

modifier 59 is attached to the “bundled” or

column 2 code.

(14)

Why is modifier 25 a concern?

• The OIG published a special report on modifier

25 usage, which is located at:

• http://oig.hhs.gov/oei/reports/oei-07-03-00470.pdf

OIG Report

According to this report:

• 35% of claims using modifier 25 that Medicare

allowed in 2002 did not meet program

requirements, resulting in $538 million in

improper payments

OIG Report

According to this report:

• Medicare should not have allowed payment for

these claims because the E/M services were

not significant, separately identifiable, and

above and beyond the usual preoperative and

postoperative care associated with the

procedure…

(15)

Why is modifier 59 a concern?

• Incorrect usage of modifier 59 is a huge

concern for payors, Medicare and the OIG:

• Some payors have published guidelines or

policies regarding modifier 59, for example:

– Blue Cross & Blue Shield of Tennessee

(http://www.bcbst.com/providers/code_bundling/docs/ ReviewCriteriaforModifier59.pdf )

– Cigna

(https://my.cigna.com/teamsite/health/provider/medical /edits/pdf/Modifier25_59_ExternalUpdate.pdf )

OIG Report

• In March 2011, the OIG published their list of

unimplemented recommendations. In it is a

section on the use of modifier 59. This

publication is available at:

• https://oig.hhs.gov/publications/docs/compendiu

m/2011/CMP-01_Medicare_A+B.pdf

OIG Report

According to this report:

• The OIG found providers had a 40% or more

error rate for services billed with a 59 modifier.

• The OIG recommended that:

– “CMS should (1) encourage carriers to conduct prepayment and postpayment reviews of the use of modifier 59 and (2) ensure that the carriers’

claims‐processing systems pay claims with modifier 59 only when the modifier is billed with the correct code.”

(16)

OIG Report

Also included in this report is a list of actions

taken by CMS:

• In April 2006, CMS published clarifying guidance to chapter 4 of the Medicare Claims Processing Manual, which includes the use of modifier 59 (CR 4388).

• In April 2008, CMS issued an MLN Matters article (classified as Special Edition 0810) to provide continuing education to physicians on how to bill modifier 59 appropriately.

• In its December 2009 comments, CMS indicated that it would explore the development of an edit for modifier 59. However, upon further analysis in this area, CMS discovered that the implementation of creating an edit for modifier 59 would likely result in increased appeals volume.

• In its update for 2011, CMS indicated that it will continue to explore alternative solutions to ensure correct coding.