Print Modifier -25

Modifier -25

 

POLICY

Introduction

Recently, we received a significant number of appeals regarding the bundling of E/M codes submitted with modifier -25 appended. An analysis of these appeals indicated that in approximately 90% of the cases, modifier -25 was used inappropriately.

Our claims editing system and our in-house policies and procedures are set-up to handle modifier -25 when the modifier is used appropriately. The overuse or misuse of this modifier causes delays in processing your claims and, in many instances, codes will be bundled in error.

Modifier -25 should be used to indicate a significant, separately identifiable Evaluation and Management (E/M) service by the same physician on the same day of the procedure or other service. Modifier -25 should be appended to E/M service codes only. It should not be appended to codes located in the Surgical, Radiology, Laboratory/Pathology, or Medicine Section of the CPT manual.

 

Modifier -25 should be used to indicate a significant, separately identifiable E/M service in the following circumstances:

  • Modifier -25 should be appended to the E/M service code when an E/M service is performed on the same day as a starred (*) procedure. If the E/M service is performed prior to or after the date that the starred surgical procedure is performed, modifier -25 should not be appended to the E/M service code.

Rationale: Services performed prior to and after the date that a starred procedure is performed are never bundled with a starred procedure. Preoperative and postoperative services are allowed on a service-by-service basis for starred procedures. Please note that a starred procedure can be identified by the symbol (*) in the CPT manual.

 

BCBSMS Honorary Starred Procedures: Below is a list of BCBSMS honorary starred procedures. Honorary starred procedures are minor surgical procedure codes that we treat the same as CPT starred procedures. The above guidelines for CPT starred procedures also apply to the list of honorary starred procedures.

 

BCBSMS HONORARY STARRED PROCEDURES

 

10000 - 1999920000 - 29999

 

30000 - 3999940000 - 49999

 

50000 - 5999960000 - 69999

 


11055

11056

11057

11100

11101

11201

11301

11302

11303

11306

11307

11308

11311

11312

11313

11719

11720

11721

11740

15787

16000

17003

17004

17111

19001

19030

 


20220

21076

21077

21116

21800

23330

23350

24220

27093

27095

27096

27370

27648

28490

28510

29000

29010

29015

29020

29025

29035

29040

29044

29046

29049

29055

29058

29065

29075

29085

29105

29125

29126

29130

29131

29200

29220

29240

29260

29280

29305

29325

29345

29355

29358

29365

29405

29425

29435

29440

29445

29450

29505

29515

29520

29530

29540

29550

29580

29590

29700

29705

29710

29715

29720

29730

29740

29750

29799

 

 

 


30100

31231

31233

31235

31320

31500

31502

31505

31510

31511

31512

31513

31515

31520

31525

31526

31527

31528

31529

31575

31576

31615

31622

31623

31624

31625

31700

31708

31710

31715

31717

31720

36005

36400

36406

36420

36425

36430

36450

36455

36620

37195

38200

38231

38790


42550

43200

43202

43234

43235

43239

44360

44361

44380

44382

44385

44386

44388

44389

45300

45303

45305

45330

45331

45378

45380

46600

46604

46606

47133

47134

47500

47505

48400

49427

 

 

 

 

 

 


50394

50684

50686

50690

51605

51610

51725

51726

51736

51741

51772

51784

51785

51792

51795

51797

52000

52005

52007

52010

52204

54056

54057

54150

54160

54230

54231

54240

54250

55859

56501

57170

58301

58323

59025

 


60001

62310

62311

62318

62319

62367

62368

64470

64472

64475

64476

64479

64480

64483

64484

64550

65436

69090

69200

69210

 

 

 

 

 

 

 


 

  • Modifier -25 should be used to indicate that an E/M service is above and beyond the normal, uncomplicated preoperative and postoperative care usually associated with a surgical procedure.

Modifier -25 is not needed if the service is performed outside of the surgical procedure's global period (preoperative and postoperative period). For example, the global surgical period for procedure code 47562 (laparoscopic cholecystectomy) is one day prior to the date of surgery and 90 days after the date of surgery. If a significant, separately identifiable E/M service is performed during the global surgical period indicated above for procedure code 47562, modifier -25 should be appended to the E/M service code. If the E/M service is performed before or after the global surgical period for this procedure, modifier -25 should not be appended to the procedure code.

Do not append modifier -25 to the critical care and neonatal intensive care codes (99291-99298) when these services are performed during the preoperative and postoperative period of a surgical procedure. The critical care and the neonatal intensive care codes are by nature significant, separately identifiable services. These codes are never bundled with the surgical procedure codes.

Do not use modifier -25 on postoperative visits when the surgical procedure has no postoperative follow-up days. Postoperative visits for procedures with no postoperative follow-up days will be allowed on a service-by-service basis. The postoperative visits are never bundled with the surgical procedure codes.

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.

Please note that BCBSMS uses the CPT coding guidelines to determine the preoperative period for surgical procedures. CPT guidelines changed effective January 1, 2002. Please see new guidelines in the Surgery Guidelines, which are located at the very beginning of the Surgery Section of the 2002 CPT manual.

BCBSMS uses the follow-up days from the Resource Based Relative Value Scale (RBRVS) to determine the postoperative period for surgical procedures. The postoperative follow-up days for 2002 can be found in the Federal Register, Volume 66, No. 212, November 1, 2001, Rules and Regulations. You can purchase a copy of this volume of the Federal Register for a minimal fee by calling (202)512-1800.

You can also download the file from the internet. The website is www.hcfa.gov/stats/profiles.htm#payrate. The filename is "National Physician Fee Schedule Relative Value File."

  • Modifier -25 should be used to indicate a significant, separately identifiable E/M service performed on the same day as another procedure which includes preservice and postservice work. Examples of such codes are the immunization administration codes (90471-90474), the chemotherapy codes (96400-96549), osteopathic manipulative treatment codes (98925-98929), chiropractic manipulative treatment codes (98940-98943), etc. As mentioned above, there are other coding situations such as these that require the use of modifier -25 when an E/M service is billed on the same day. Listed above are just a few examples.

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.

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.

Decision for Surgery

When applicable, modifier -57 should be appended to the E/M service code to indicate that the initial decision to perform surgery was made during the visit.

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 EXCEPTIONS

None

 

POLICY GUIDELINES

The coding guidelines outlined in Coding Policy should not be used in lieu of the Member's specific benefits plan language.

 

POLICY HISTORY

1/2003: Policy developed

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