Comparative Billing Reports

CBR201613 Modifier 25: Obstetrics/Gynecology (OB/GYN) FAQs

Question Categories

General

Clinical and Billing

Report Specifics

 

General

 

Why was Modifier 25 selected as a topic for a comparative billing report (CBR)?

Modifier 25 was chosen as a topic for a CBR because the Office of Inspector General (OIG) determined that modifier 25 is an area that is vulnerable to fraud, waste, and abuse. Findings from an OIG investigation indicated that some evaluation and management (E/M) claims with modifier 25 were billed incorrectly, resulting in improper payments of as much as $538 million. The report revealed that many providers appended modifier 25 to more than 50 percent of the services they billed, while other providers used modifier 25 on their E/M services when no other services were performed on the same day. To review details of that OIG report, see the following web link: Use of Modifier 25.

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What is the purpose of a comparative billing report (CBR) for Modifier 25-Obstetrics/Gynecologist (OBGYN)?

CBR201613 was created to inform OB/GYN Medicare providers about their billing and payment patterns on E/M claims appended with modifier 25. The CBR team reviewed Fee-for-Service Medicare (Original Medicare) claims with dates of service from January 1, 2015 to December 31, 2015. For more information about CBRs, please visit our website at the link titled, Comparative Billing Reports.   

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What CPT® codes were analyzed?

The chart below lists the Current Procedural Terminology (CPT®) codes, abbreviated descriptions, and typical times included in this CBR:

 

CPT® Code

Abbreviated Description

Typical Time

99211

Minimal Problem/Exam

  5 Minutes

99212

Problem Focused/Exam

10 Minutes

99213

Expanded Problem Focused/Exam

15 Minutes

99214

Detailed Patient History/Exam

25 Minutes

99215

Comprehensive Patient History/Exam

40 Minutes

 

Please refer to the CPT® 2015 Professional Edition Manual for complete descriptions of the CPT® codes. The manual can be accessed from the American Medical Association (AMA) website at the link, AMA Store.

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What is the specific focus of CBR201613? 

CBR201613 focuses on providers who billed differently than their peers. The metrics included in the report are:

  • Percentage of services with modifier 25 appended
  • Average allowed minutes per visit for claim lines with modifier 25 and without modifier 25
  • Average allowed charges per beneficiary summed for the one-year period, regardless of the modifiers appended to the claim lines

To review an example of a mock provider’s CBR, see the following link: CBR201613 Sample CBR.

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How were providers selected, and how many received CBRs?

The CBR data team analyzed claims with allowed services for the CPT® codes included in this CBR and identified those providers with different billing patterns compared to their peers. Approximately 4,800 providers were selected to receive the reports; however, providers who did not receive a CBR can view a mock report at the following link: CBR201613 Sample CBR.

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Does receiving a CBR indicate incorrect billing by a provider?

No. Receiving a CBR does not necessarily mean a provider is billing incorrectly; however, it does mean that a provider’s billing is different from their peers. There are many reasons billing patterns may vary, which include region, subspecialty, and patient acuity. If you still have questions and/or concerns after reviewing your CBR, please contact the CBR Support Help Desk by telephone at 1-800-771-4430 or by email at CBRSupport@eglobaltech.com

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Should a provider expect an audit if they received a CBR?

No. Receiving a CBR letter is not an indication of an impending audit. The CBR team does not have access to medical records to perform audits of claims, and the CBR letter is not punitive or an indication of wrongdoing. The purpose of CBRs is to allow providers to compare their billing patterns to those of their peers; however, it may be beneficial for providers to conduct self-audits. Resources that can help with setting up an audit process are located on our CBR website page at the link titled, Self-Audit Help.

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Does the information in the CBR change or alter the documentation and billing requirements established by the Medicare Administrative Contractors (MACs)?

No. The CBR is for informational and educational purposes. It does not alter, change, or negate any of the documentation and billing requirements established by the MACs.

If you have questions about billing, please use the following CMS website to access the contact information for your MAC: Review Contractor Directory – Interactive Map.

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Clinical and Billing

 

What is a modifier?

A modifier is a two-digit value that is added to CPT® codes and Healthcare Common Procedure Coding System (HCPCS) codes. Modifiers are used to show that the service is different in some way without changing the definition or meaning of the service. Modifiers also add specificity and improve the accuracy of coding. To find help with calculating payments and selecting modifiers, see the following link: Physician Fee Schedule Search. Providers can find detailed Instructions in the Medicare Learning Network® publication at the web link titled, How to Use the Searchable Medicare Physician Fee Schedule (MPFS).

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What is the definition of modifier 25?

According to the CPT® Manual, modifier 25 describes a “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.” Modifier 25 is used to bypass the edits that bundle payments of E/M services into the procedure performed on the same day by the same provider. The CPT® Manual is available from the American Medical Association (AMA) website at the link titled, AMA Store.

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Why is modifier 25 required?

Modifier 25 is required when the E/M code is billed on the same day as a minor procedure and when the service is above and beyond what would normally be required for the procedure. If an E/M service is billed on the same day as a minor procedure carrying a 000 or 010 day global period without modifier 25, the E/M service will deny as bundled into the procedure.

Per the National Correct Coding Initiative (NCCI) Policy Manual, (Chapter I, Section E), “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.” For minor procedures, modifier 25 should only be appended to the claim when the evaluation and management performed was over and above what would normally be required for the procedure. The NCCI Policy Manual can be accessed through the CMS website at the web link titled, National Correct Coding Initiative Edits, and more information regarding Medicare Global Surgery rules can be found at the web link titled, NCCI Policy Manual, Chapter I, Section E.

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When is it appropriate to append modifier 25 to claims?

Per the NCCI Policy Manual, “Modifier 25 may be appended to an evaluation and management (E&M) CPT code to indicate that the E&M service is significant and separately identifiable from other services reported on the same date of service. The E&M service may be related to the same or different diagnosis as the other procedure(s).” If an E/M service is billed on the same day as a minor procedure carrying a 000 or 010 day global period without appending modifier 25, the E/M service will deny as bundled into the procedure. To review more information, please see the following link: NCCI Policy Manual, Chapter I, Section E.

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Is a different diagnosis required for the E/M portion of the claim?

No. The diagnosis for the E/M service and the procedure may be the same or different. If the diagnosis is the same for both codes, the work involved in the separate E/M should be over and above what is normally required for the procedure.

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Can modifier 25 be used for codes other than E/M services?

No. According to the CPT® Manual, modifier 25 identifies a “significant, separately identifiable evaluation and management (E/M) service. It should be used when the E/M service is above and beyond the usual pre- and postoperative work of a procedure with a global period performed on the same day as the E/M service.” Modifier 25 is appended only to the E/M portion of the claim. For significant and separately identifiable non-E/M services, modifier 59 may be appropriate. The CPT® Manual is available from the AMA website at the link, AMA Store.  

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Can another practitioner in the same group practice with the same specialty bill an E/M service on the day of a procedure?

The answer depends on the reason for the visit. Chapter 12 of the Medicare Claims Processing Manual states the following: “Physicians in the same group practice who are in the same specialty must bill and be paid as though they were a single physician. If more than one evaluation and management (face-to-face) service is provided on the same day to the same patient by the same physician or more than one physician in the same specialty in the same group, only one evaluation and management service may be reported unless the evaluation and management services are for unrelated problems. Instead of billing separately, the physicians should select a level of service representative of the combined visits and submit the appropriate code for that level. Physicians in the same group practice but who are in different specialties may bill and be paid without regard to their membership in the same group.” To review this information, please see the following link: Medicare Claims Processing Manual, Chapter 12, Section 30.6.5.

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If a problem is noted on the day of a minor procedure which requires no additional work on the part of the physician, can an E/M be billed with modifier 25 appended?

No. By the very definition of the modifier, the additional evaluation and management must be significant. For a claim to be able to withstand an audit, the additional work involved must be clearly documented in the patient’s medical record. Insignificant or minor problems that do not require additional work should not be reported separately. For additional information, select the following web link: Medicare Claims Processing Manual, Chapter 12, Section 30.6.1.1.

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Can an additional evaluation and management service be billed when the patient receives an Annual Wellness Visit (AWV) or Initial Preventive Physical Examination (IPPE)?

Yes. According to Chapter 12 of the Medicare Claims Processing Manual (Section 30.6.1.1), “When the physician or qualified NPP, or for AWV the health professional, provides a significant, separately identifiable medically necessary E/M service in addition to the IPPE or AWV, CPT® codes 99201-99215 may be reported depending on the clinical appropriateness of the circumstances. CPT® Modifier -25 shall be appended to the medically necessary E/M service identifying the service as a significant, separately identifiable service from the IPPE or AWV code reported (HCPCS code G0344 or G0402, whichever applies based on the date the IPPE is performed, or HCPCS code G0438 or G0439 whichever AWV code applies).

Note: Some of the components of a medically necessary E/M service (e.g., a portion of history or physical exam portion) may have been part of the IPPE and AWV and should not be included when determining the most appropriate level of E/M service to be billed for the medically necessary, separately identifiable, E/M service.”  This information can be found at the web link titled, Medicare Claims Processing Manual, Chapter 12, Section 30.6.1.1.

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What kind of documentation does Medicare require to be in the medical record in order to append modifier 25 to the claim?

According to the Medicare Claims Processing Manual (Chapter 12, Section 30.6.6), “Both the medically necessary E/M service and the procedure must be appropriately and sufficiently documented by the physician or qualified nonphysician practitioner in the patient’s medical record to support the claim for these services, even though the documentation is not required to be submitted with the claim.” Documentation for the separately billed E/M service must support the level of service billed. In other words, no part of the documentation for the E/M service can be used to support the performance of the procedure. Specific documentation requirements are found on the CMS web page at Medicare Claims Processing Manual, Chapter 12, Section 30.6.6.

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What is a global surgical package?

Medicare has established a national definition of a global surgical package. According to Medicare, the global surgical package “includes all necessary services normally furnished by a surgeon before, during, and after a procedure. Medicare payment for the surgical procedure includes the pre-operative, intra-operative, and post-operative services routinely performed by the surgeon or by members of the same group with the same specialty.” To review this information, please see the Medicare Learning Network® link titled, Global Surgery Fact Sheet.

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What types of services are routinely included in the global surgical package?

According to the CPT® 2015 Professional Edition, “In defining the specific services ‘included’ in a given CPT® surgical code, the following services are always included in addition to the operation per se:

  • Local infiltration, metacarpal/metatarsal/digital block or topical anesthesia
  • Subsequent to the decision for surgery, one related Evaluation and Management (E/M) encounter on the date immediately prior to or on the date of procedure (including history and physical)
  • Writing orders
  • Evaluating the patient in the post anesthesia recovery area
  • Typical postoperative follow-up care.”

The CPT® 2015 Professional Edition is available from the American Medical Association (AMA) at the link, AMA Store.

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How can I find the global period for a specific procedure?

The Medicare Physician Fee Schedule Database (MPFSDB) website provides information on services that are covered by Medicare. The Physician Fee Schedule (PFS) look-up website page allows you to search the following: price, payment policy indicators, relative value units (RVUs), geographic practice cost index (GPCI) and the national payment amount. To select your search criteria, start at the following link: Physician Fee Schedule Search.

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How many different global periods are there?

There are seven different global periods assigned to various procedures and services. They are described, as follows:

  • 000

Zero global days

  • 010

Ten global days

  • 090

Ninety global days

  • XXX

Global concept does not apply

  • YYY

Defined by A/B MAC

  • ZZZ

Related to another procedure

  • MMM

Maternity codes, usual global period does not apply

To review more details about global periods, visit the following website link: Medicare Claims Processing Manual, Chapter 12, Section 40 – Surgeons and Global Surgery.

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What are the services included in minor surgical procedures?

According to Chapter I of the NCCI Policy Manual, “Minor surgical procedures and XXX procedures include pre-procedure, intra-procedure, and post-procedure work inherent in the procedure… 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 provider should not report an E/M service for this work. For more information on NCCI rules, please see the following link: NCCI Policy Manual, Chapter I, Section E.

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What is the global period for a minor surgical procedure?

For a minor procedure, the patient visit on the day of the procedure is generally not paid as a separate service, and there is no payment for pre-operative and post-operative days. TheMedicare Claims Processing Manual gives the following example of a minor surgery: 

“…a visit on the same day could be properly billed in addition to suturing a scalp wound if a full neurological examination is made for a patient with head trauma. Billing for a visit would not be appropriate if the physician only identified the need for sutures and confirmed allergy and immunization status. A postoperative period of 10 days applies to some minor surgeries. The postoperative period for these procedures is indicated in Field 16 of the MFSDB. If the Field 16 entry is 010, A/B MACs (B) do not allow separate payment for postoperative visits or services within 10 days of the surgery that are related to recovery from the procedure.”

For more details about minor procedures, see the following link: Medicare Claims Processing Manual, Chapter 12, Section 40.1 (C).

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Report Specifics

 

How were claims data obtained for this report?

Claims with CPT® codes covered in this CBR with dates of service from January 1, 2015 to December 31, 2015 were downloaded from the CMS Integrated Data Repository (IDR) and loaded into the Palmetto GBA Medicare Data Warehouse. The providers’ data (as identified by NPPES) was compared to peers located in their states and the nation. For more information about the IDR, see the following link: CMS Integrated Data Repository (IDR).

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Can you explain what Table 1 means?

Table 1 is a list of CPT® Codes, Abbreviated Descriptions, and Typical Times included in this CBR. To review an example of a mock provider’s report, see the following: CBR201613 Sample CBR.

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What does Table 2 mean?

Table 2 is titled Summary of Your Utilization for E/M Codes and Modifier 25. It lists the mock provider’s CPT® codes, modifier (with or without modifier 25), allowed charges, allowed services, and beneficiary count for each item. For an illustration, refer to Table 2 of the mock provider’s CBR at the web link titled, CBR201613 Sample CBR.

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How are the peers defined?

Each billing provider was identified by National Provider Identifier (NPI). The peer groups that are used for comparison with individual providers were identified, as follows:

  • State: All Medicare Part B providers with a specialty of OB/GYN (16) with allowed charges for CPT® codes 99211-99215 that are in the same state, as indicated in the National Plan and Provider Enumeration System (NPPES)
  • National: All Medicare Part B providers in the nation with a specialty of OB/GYN (16) with allowed charges for CPT® codes 99211-99215, as indicated in NPPES

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What do the comparison outcomes mean?

The four possible outcomes for the comparisons between the provider and peer groups are:

  • Significantly Higher - provider’s value is higher than the peer value and the statistical test used confirms significance
  • Higher – Provider’s value is higher than the peer value, but either the statistical test does not confirm significance or there is insufficient data for comparison
  • Does Not Exceed - provider’s value is not higher than the peer value
  • N/A (Not Applicable) - Provider does not have sufficient data for comparison

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What does Table 3 mean? 

Table 3 compares the mock provider’s Percentage of Services with Modifier 25 to that of their state and nation. To illustrate this, see Table 3 of the CBR at the following link:CBR201613 Sample CBR. The results of this analysis show the provider is Significantly Higher than their state and Higher than the national peer group, according to the results of the chi-test. To view the results for each state and the nation, see the following link: CBR201613 Statistical Debriefing.  

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What does Table 4 mean? 

Table 4 provides a comparison of the mock provider’s Average Allowed Minutes per Visit with Modifier 25 and without Modifier 25 to that of their state and nation. For illustration, refer to Table 4 of the CBR at the link: CBR201613 Sample CBR. In this example, the provider has 19.79 average allowed minutes per visit with modifier 25, which is Significantly Higher than the state’s average of 16.70 and Higher than the national average of 19.11. The provider has 18.07 average allowed minutes per visit without modifier 25. This is also Significantly Higher than the state’s average of 17.22; however, it Does Not Exceed the national average of 18.27. To review the results for each state and the nation, select the following link: CBR201613 Statistical Debriefing.  

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Can you explain Table 5?

Table 5 compares the mock provider’s Average Allowed Charges per Beneficiary to that of their state and nation. For illustration, please refer to the CBR at the web link, CBR201613 Sample CBR. In this example, the provider’s average allowed charges per beneficiary were $149.06. The provider’s average is Significantly Higher than the state’s percentage of $105.80 and Higher the nation’s percentage of $127.04. The results of the analysis for each state and the nation can be reviewed at the following link: CBR201613 Statistical Debriefing

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How were allowed charges calculated in this CBR?

Allowed charges for this CBR were calculated based on the Medicare Physician Fee Schedule (MPFS). Payment can vary depending on the carrier locality, the type of facility where the service was rendered, the number of units billed, and the use of a modifier. In most instances, Medicare pays the provider 80 percent of the fee schedule allowed amount, and the patient is responsible for the balance of the payment; however, there are some exceptions to this rule. To search for payment rates in the MPFS, see the web link, Medicare Physician Fee Schedule Look-Up Tool.

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My allowed charges are “Significantly Higher” than the peer groups on my report. Are my allowed charges being compared to providers in other states that have lower fee schedule amounts?

Medicare Physician Fee Schedule (MPFS) allowed amounts vary from area to area. These comparisons are provided so that a provider may get a better idea of where they stand in comparison to providers in their state and the nation.  A geographic practice cost index (GPCI) has been established to account for the variation in practice expenses across states and nation. More information on the GPCI is available on the CMS website at the link, Documentation and Files - National Physician Fee Schedule and Relative Value Files.

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Where can providers find more information about modifier 25?

Tables containing data for this CBR can be accessed at the web link titled, CBR201613 Statistical Debriefing, and links for the references and resources used in this CBR can be found at CBR201613 Recommended Links.  Providers should contact their MACs with questions about specific claims and/or billing. For contact information, select the following CMS web link: Medicare Administrative Contractors (MACs).

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