Modifier -25 (New Policy)
The starred procedure designation was deleted in the Current Procedural Terminology 2004 coding manual. Revisions have been made within this policy that supports this change with guidelines that are in-line with the current CPT4. This policy is effective for claims processed on or after April 1, 2006, regardless of the service date.
Because we receive a significant number of claims with modifier -25 appended, excerpts from CPT4 are included in the policy to help provide coding criteria for correct usage of modifier -25.
Our claims editing system and our in-house policies and procedures are set-up to handle modifier -25 when the modifier is used appropriately. Misuse of this modifier causes delays in processing your claims and, in many instances, codes will be denied. In addition, there may be times when medical records are requested for claims submitted with modifier -25.
Modifier -25 should be used to indicate a significant, separately identifiable E/M service in the following circumstances:
Rationale: As mentioned above these procedure codes usually include preservice and postservice work. An E/M service is not routinely billed on the same day as these procedure codes. If a significant, separately identifiable E/M service is performed on the same day, modifier -25 should be appended to the E/M code.
Modifier -25 should not be used to indicate a significant, separately identifiable E/M service in the following circumstances:
Rationale: According to CPT coding guidelines, only the services that fall within the global surgical period are considered an integral part of performing the procedure. E/M services outside of a procedure's global surgical period are allowed on a service-by-service basis.
BCBSMS uses the CPT coding guidelines to determine the preoperative period for surgical procedures. Please see guidelines in the Surgery Guidelines, which are located at the very beginning of the Surgery Section of the CPT manual.
BCBSMS uses the follow-up days from the Resource Based Relative Value Scale (RBRVS) to determine the postoperative period for surgical procedures.
To determine when modifier -25 is needed, please read the introductory notes at the beginning of the section of the procedure performed on the same day as the E/M service or check the coding guidelines for the procedure with a reliable coding resource.
Note: The guidelines regarding the determination of the preoperative and postoperative period are specific to BCBSMS. Other carriers may use different resources to determine the global surgical period.
POLICY GUIDELINESThe coding guidelines outlined in Coding Policy should not be used in lieu of the Member's specific benefits plan language.
POLICY HISTORY4/2006: Policy revised to remove information regarding starred procedures.
6/2008: Policy revised to add statement "In addition, medical records may be requested for claims submitted with modifier -25."