Depends on how the insurance carrier reviewer was feeling that day.
Modifier -25
The services described in policies are subject to the terms, conditions and limitations of the Member's contract or certificate. Unless otherwise stated, policies do not apply to Medicare Advantage enrollees.
XYZ reserves the right, in its sole discretion, to modify policies as necessary without prior written notice unless otherwise required by XYZ's administrative procedures. The term XYZ includes XYZa, LLC and all of its subsidiaries as appropriate for these policies as well as XYZb and XYZc. Certain policies may not be applicable to Self-Funded Members and certain insured products. Refer to the Member's plan of benefits or Certificate of Coverage to determine whether coverage is provided or if there are any exclusions or benefit limitations applicable to any of these policies. If there is a difference between any policy and the Member's plan of benefits or Certificate of Coverage, the plan of benefits or Certificate of Coverage will govern. Policy #: ADMINISTRATIVE 116.4 T0
Coverage Statement: Policy is applicable to:
Purpose The purpose of this document is to outline policy on evaluation and management services billed with other procedures/services, and the
rules XYZ applies to the use of Modifier -25.
Definitions Modifier -25 - (as defined by the American Medical Association
Current Procedural Terminology: CPT 2005, Professional Edition) Significant, Separately Identifiable Evaluation and Management Service by the Same Physician on the Same Day of the Procedure or Other Service. The modifier was created for situations when the physician needs 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 identifiable 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. The E/M service may be prompted by the symptom or condition for which the other procedure and/or service was provided. As such, different diagnoses are not required for reporting of the E/M services on the same date. This circumstance may be reported by adding modifier '25' to the appropriate level of E/M service. Modifier 25 is used to identify a significant, separately identifiable evaluation and management service performed on the same day as another procedure or service by the same provider.
Global Days - The global period is the number of days during which all necessary services normally furnished by a physician (before, during, and after the procedure) are included in the reimbursement for the procedure performed. Refer to policy:
Global Surgical Package.
Evaluation and Management Services (E/M) - CPT codes 99201-99499 are considered Evaluation and Management codes. The types of E&M services include examinations, evaluations, treatments, conferences with or concerning patients, preventive pediatric and adult health supervision, and similar medical services, such as the determination of the need and/or location for appropriate care and treatment of a patient (e.g., office and outpatient setting, emergency department, nursing facility, etc.).
Procedure/Service (as defined for this policy) - medical services other than an E&M code that has a global days allowance (of 0, 10, 49 or 90).
Policy XYZ follows the Centers for Medicare and Medicaid (CMS)
guidelines in reimbursing both an E/M Service and a Procedure/Service having a global days allowance (of 0, 10, or 90) when performed on the same date of service and involving a significant, separately identifiable E/M service above and beyond the other service provided. In addition, XYZ will reimburse non-OB related office Evaluation and Management (E/M) services in addition to global antepartum care when submitted with a -25 modifier.
Exception to the global period and use of Modifier 25:An E/M Service will be paid on the same day as a Procedure/Service when a claim is submitted with the CPT/HCPCS code for the procedure with modifier 25 appended as follows:
- The patient's condition required a significant, separately identifiable E/M service above and beyond the Procedure/Service provided.
- E/M Services were provided above and beyond the usual preoperative and postoperative care associated with the Procedure/Service that was performed.
NOTE: E/M Services as well as Procedures/Services of physicians and other health care professionals of the same specialty within the same group with the same federal tax identification number are considered as having been performed by the same physician/provider.
XYZ will monitor modifier usage and frequency for appropriate billing of the modifier.
Procedures and Responsibilities The following guidelines also apply
- The initial E/M consultation or evaluation of the problem by the physician to determine the need for surgery or procedure are excluded from the global period and are always payable with or without modifier 25.
- Non-OB related office Evaluation and Management (E/M) services in addition to global antepartum care when submitted with a -25 modifier.
- Separately identifiable E/M services performed by the physician on the same day of service are reimbursable when submitted with a -25 modifier, provided the use of the modifier meets the above requirements. Refer to: