8/19/2017. The OIG Report

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1 This presentation was created by me with the best intentions and believable resources. I however am not a lawyer, doctor or self-proclaimed expert, but I have watched plenty on TV. The information and sources are as accurate as I could get them, however if you go back to your office saying Linda said so, youwill get funny looks. The OIG Report 1

2 The guidelines are not great We are asking for extra money That won t pay without a 25 The OIG decided it was worth a look Came out in 2005 Used claims from 2002 In 2002, Medicare allowed $1.96 billion for approximately 29 million services billed using modifier randomly selected claims 431 providers were able to be contacted, Other 19 claims were excluded 35% of claims using modifier 25 that Medicare allowed in 2002 did not meet program requirements These claims totaled $538 million in improper payments that Medicare and/or beneficiaries made. The payments were improper because the services were deemed (1) noncovered because they did not meet the requirements for use of modifier 25 or (2) undocumented due to failure to meet basic Medicare documentation requirements 2

3 Twenty-eight percent of all providers in the sample population used modifier 25 on more than 50 percent of their claims, thus using it unnecessarily. Claims submitted for some providers included the modifier on every item billed to Medicare in 2002 both procedures and E/M services. Evaluation and management (E/M) services that are necessary for the performance of a medical procedure (for example, assessing the site/condition of the problem area, explaining the procedure, and obtaining informed consent) are includedin Medicare payments for the procedure. 3

4 The governing source for determining appropriate payment is CMS s Internet- Only Manual. Chapter 12, section 40.2 of the manual states: Modifier 25 is used to facilitate billing of evaluation and management services on the day of a procedure for which separate payment may be made. It is used to report a significant, separately identifiable evaluation and management service performed by the same physician on the day of a procedure. The physician may need to indicate that on the day a procedure or service that is identified with a CPT code was performed, the patient s condition required a significant, separately identifiable evaluation and management service above and beyond the usual preoperative and postoperative care associated with the procedure or service that was performed. Significant, Separately Identifiable Evaluation and Management Service by the Same Physician or Other Qualified Health Care Professional on the Same Day of the Procedure or Other Service It may be necessary 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. A significant, separately identifiable E/M service is defined or substantiated by documentation that satisfies the relevant criteria for the respective E/M service to be reported. The E/M service may be prompted by the symptom or condition for which the 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. Note: This modifier is not used to report an E/M service that resulted in a decision to perform surgery. 4

5 The CPT codes for procedures do include the evaluation services necessary prior to the performance of the procedure (e.g., assessing the site/condition of the problem area, explaining the procedure, obtaining informed consent), however, when significant and identifiable (i.e., key components/counseling) E/M services are performed, these services are not included in the descriptor for the procedure or service performed. Medical record documentation should include: Clinical information confirming that the E/M service billed was above and beyond the E/M services included in the procedure The physician pre-service work for the skin biopsy includes: discussion of probable diagnoses and indication for the biopsy procedure, risks and benefits, description of biopsy procedure method, and expected result or scar. An informed consent is obtained. 5

6 Does the CPT have a global period? Does the CPT have a Pre-Op period? 6

7 Closed Treatment of metatarsal fracture; without manipulation, each EGD with biopsy 7

8 XXX indicator Does the global concept apply? Let s just add the 25 to be safe WPS Modifier 25 Fact Sheet Appropriate usage: The procedure performed has a global period listed on the Medicare Fee Schedule Relative Value File. This global period could be 000, 010, or 090 days Chest X-ray 8

9 Modifier 25 may be appended to E&M services reported with minor surgical procedures (global period of 000 or 010 days) or procedures not covered by global surgery rules (global indicator of XXX). Since minor surgical procedures and XXX procedures include pre-procedure, intra-procedure, and post-procedure work inherent in the procedure, the provider should not report an E&M service for this work. Furthermore, Medicare Global Surgery rules prevent the reporting of a separate E&M service for the work associated with the decision to perform a minor surgical procedure whether the patient is a new or established patient. The following statements are false I can always use this modifier when I did not plan the procedure. I can always use this modifier when the diagnoses are different. I can never use this modifier when the diagnoses are the same. An E&M service is separately reportable on the same date of service as a procedure with a global period of 000, 010, or 090 under limited circumstances If a procedure has a global period of 000 or 010 days, it is defined as a minor surgical procedure. In general E&M services on the same date of service as the minor surgical procedure are included in the payment for the procedure. 9

10 CCI MANUAL: The decisionto perform a minor surgical procedure is included in the payment for the minor surgical procedure and should not be reported separately as an E&M service If a minor surgical procedure is performed on a new patient, the same rules for reporting E&M services apply. The fact that the patient is new to the provider is not sufficient alone to justify reporting an E&M service on the same date of service as a minor surgical procedure IOM Ch.12: What is not included in the Surgical package: Initial consultation or evaluation of the problem by the surgeon to determine the need for surgery. Please note that this policy only applies to major surgical procedures.; The initial evaluation is always included in the allowance for a minor surgical procedure 10

11 IOM Ch.12: Visits by the same physician on the same day as a minor surgery or endoscopy are included in the payment for the procedure, unless a significant, separately identifiable service is also performed. Where the decision to perform the minor procedure is typically done immediately before the service, it is considered a routine preoperative service and a visit or consultation is not billed in addition to the procedure Does not have to be different but don t put a different one just to get paid Different diagnoses are not required for reporting the E/M service on the same date as the procedure or other service with a global fee period. Modifier - 25 is added to the E/M code on the claim CMS Transmittal

12 To decide if an E&M service is separately reportable with modifier 25, AAPCsuggests: Ask yourself, Can I pick out from the documentation a clear history, exam, and [medical decision making] apart from any other procedures the physician performs on the same day? If so, you ve probably got a billable service with modifier When modifier 25 is appropriately appended to an E&M service and is submitted on the same date of service, by the same professional provider or other qualified health care provider, as a minor procedure, the E&M service is reimbursed at 50 percent of the applicable fee schedule amount. 12

13 Payments for E&M services with a 25 modifier exceeded $2.5 billion in 2015 A physician examines a patient with a fever, headache, vomiting, and stiff neck. A spinal tap is performed as well as the services described in code The -25 modifier is appended to code to indicate that both a significant E/M service and a procedure were performed on a given day. Winter 1993, CPT Assistant 13

14 A physician examines a new patient exhibiting symptoms of an upperrespiratory infection that has progressed to unilateral purulent nasal discharge and discomfort in the right maxillary teeth. The physician performs and documents a detailed history and detailed examination. The physician determines that the medical decision making is of low complexity and also documents this in the patient s medical record. During the examination, the patient communicates to the physician that the hearing in his left ear is not as distinct as his right ear. Upon examination of the left ear, the physician notes a large amount of impacted cerumen. The physician proceeds to remove the impacted cerumen in the patient s left ear. To report this patient encounter, the physician appends Modifier -25 to code 99203, and separately reports code 69210, Removal impacted cerumen (separate procedure), one or both earsto indicate that both a significant E/M service and a procedure were performed on a given day. May 2003, CPT Assistant If a physician determines that a new patient with head trauma requires sutures, confirms the allergy and immunization status, obtains informed consent, and performs the repair, an E&M service is not separately reportable. However, if the physician also performs a medically reasonable and necessary full neurological examination, an E&M service may be separately reportable. CCI Manual, Chapter 1 A patient was scheduled to have a lesion removed from her right leg. The physician examined the lesion, infiltrated the lesion with 1% lidocaine. The lesion was removed, and a simple closure (11401) was performed. 14

15 An established patient visited her internist for a follow up of hypertension and diabetes. The patient also complained of shoulder pain. The physician performed a problem focused history and exam, evaluated the patients' hypertension, and determined the blood pressure was higher than usual and adjusted the medication regimen. The patient's blood glucose was normal. The physician also evaluated the shoulder and determined the patient would benefit from an arthrocentesis. At a follow-up visit for the patient s stable hypertension and osteoarthritis, the patient also complains of a troublesome skin lesion that you remove at that same encounter. A 4-year-old slips on the edge of a pool, strikes the mandible and experienced a 3.5 cm serrated and curvilinear, full-thickness laceration of the chin. She is a new patient in urgent care, and the physician elects to widely excise the serrated skin margins and undermine the dermis from the subcutaneous tissue to reduce the tension on the suture line. The wound is then approximated in layers with absorbable interrupted sutures and a running subcuticular closure. 15

16 45 year old diabetic in for wound care of a buttock ulcer. This is the third visit in the past 6 weeks. The physician removes the bandage and re-evaluates the wound deciding to continue with forcep debridement, replacement of the bandage, and asks the patient to come back in 2 weeks. Modifier -25 is not the same as modifier -57, decision for surgery for a major procedure. Modifier - 25 should never be used solely as decision for surgery for a minor procedure. According to CMS, visits by the same physician on the same day as a minor surgery or endoscopy are included in the payment for the procedure. In addition, it does not matter if it is a new or an established patient. The rule is the same for both. 16

17 You do not have to have another different. diagnosis to report an EM service and a procedure on the same day If a provider sends you an EM service and a procedure on the same day with the same diagnosis and the provider did not indicate modifier -25 on the billing information, you cannot automatically apply modifier -25. You must review the documentation to make sure modifier -25 is appropriate. There is no such thing as automatically assigning modifier Is the provider is looking for a more significant or systemic issue outside of the complaint? 2. Is the exam more extensive? 3. Does the medical decision making reflect differential diagnoses and/or additional 17

18 Whether or not to apply modifier -25 will most often be a judgement call based on the documentation. Unfortunately, there is no one case fits all answer to the modifier -25 issue. Linda Vargas, CPC, CPCO, CPMA, CPC-I, CEMC, CCC, AAPC Fellow lvargas@upamed.org 18