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POLICY

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

• 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

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