What is the purpose of this comparative billing report (CBR) on modifier 25?
CBR201708 was created to inform dermatologists about their billing and payment patterns on claims appended with modifier 25 for evaluation and management (E/M) services. This CBR examines Current Procedural Terminology (CPT®) codes 99211 through 99215, and included only Fee-for-Service Medicare (Original Medicare) claims for services rendered from April 1, 2016 through March 31, 2017. For more information about CBRs, please select this website link titled Comparative Billing Reports.
Why was Modifier 25 - Dermatology chosen as a topic for a CBR?
We selected this topic because Medicare costs for dermatology are increasing due to incorrect reporting of modifier 25 for E/M services. According to an Office of Inspector General (OIG) report, at least 35 percent of services provided did not meet Medicare Program requirements. The OIG determined that some services were not significant, separately identifiable, or above and beyond the usual care. To read the entire OIG article, please select the following web link: Use of Modifier 25.
How many providers received CBRs?
CBR201708 was sent to approximately 3,500 Medicare providers with the specialty of dermatology (07) submitted on their claims. Each CBR contains a provider’s billing history and patterns and compares them to his/her peers. If you did not receive a CBR and wish to review the mock provider’s, please select the following link: CBR201708 Sample CBR.
What specifically does the report focus on?
CBR201708 focuses on dermatologists who submitted claims for established patients for E/M services appended with modifier 25. The metrics included:
- Percentage of services appended with modifier 25
- Average minutes per visit for claim lines with and without modifier 25
- Average allowed charges per beneficiary summed for the one-year period, regardless of the modifier appended to the claim lines
Does the information in the CBR change or alter the documentation and billing requirements established by the Medicare Administrative Contractors (MACs)?
The CBR is informational and educational and does not alter, change or negate any of the documentation and billing requirements established by the MACs. If you have questions about billing related to your specific claims, please contact your MAC. To find your MAC’s contact information, select this link: Review Contractor Directory – Interactive Map.
Are audits planned based on the results of CBR letters?
The CBR team does not conduct audits nor have access to the medical information needed to review claims for audits; however, we do encourage providers to take advantage of the self-audit resources available on the CBR web page located at this link: Self-Audit Help.
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 indicate 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.
What is the definition of modifier 25?
According to the CPT® Professional Edition Manual (aka 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.” The CPT® Manual is available from the American Medical Association (AMA) website located at the following link: AMA Store.
Can modifier 25 be used with CPT®codes other than E/M services?
The CPT® Manual states that modifier 25 “should be used when the E/M service is above and beyond the usual pre- and post-operative work of a procedure with a global period performed on the same day as the E/M service.” Modifier 25 should be appended to the E/M portion of the claim. The CPT® Manual is available from this web link: AMA Store.
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 appending 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), “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.” For more information on NCCI edits, please refer to the CMS website page at National Correct Coding Initiate Edits.
Can nonphysician practitioners use modifier 25 when they bill for E/M services on the same date of service as a procedure with a global period?
A. According to MLN Matters® (Number MM5025), “Physicians and qualified nonphysician practitioners (NPP) should use CPT® modifier 25 to designate a significant, separately identifiable E/M service provided by the same physician/qualified NPP to the same patient on the same day as another procedure or other service with a global fee period.” This information is found in the MLN Matters®publication at the following link: Payment for Evaluation and Management Services Provided During Global Period of Surgery.
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: “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.” For more details, select the following web link: Medicare Claims Processing Manual, Chapter 12 (Section 30.6.5).
What is a global surgical package?
According to the Medicare Learning Network® publication, 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. More detailed information is available in the Medicare Learning Network®publication at the following web link: Global Surgery Fact Sheet.
What types of services provided by the physician or nonphysician practitioner are routinely included in the global surgical package?
The CPT® Manual states, “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® Manual can be accessed from the American Medical Association (AMA) website at AMA Store.
How can providers determine the length of the global period associated with a procedure?
Providers can use the tools on the CMS website to determine the global period for a procedure. The website search criteria include the year, type of information (such as pricing), the HCPCS code(s), and the modifier type. To see how to begin a search, select the following link: Physician Fee Schedule Search.
How many different global periods are there?
CMS lists seven different global periods assigned to various procedures and services to ensure MACs are consistent with payments for the same procedures. The global periods are listed below:
000 - Zero Global Days
- - Ten Global Days
- - Ninety Global Days
- - Global Concept Does Not Apply
- - Defined by A/B MAC
- - Related to Another Procedure
- - Maternity Codes (Usual Global Period Does Not Apply)
The Medicare Learning Network® explains the components of each global period in its publication located at this link: Global Surgery Fact Sheet.
When does the global period of a procedure begin?
For those procedures which carry 000 global days, there are no pre-operative periods, no post-operative days, and visits on the day of the procedure are generally not payable as a separate service. For those procedures that carry a 010 day global period, the total global period is 11 days, including the day of the procedure and 10 days following the day of the procedure. The total global period for major procedures is 92 days and includes the day before the procedure, the day of the procedure and 90 days after the procedure. To review more on global periods, please select the following link: Global Surgery Fact Sheet.
Is a different diagnosis required for the E/M portion of the claim?
The diagnosis code(s) reported on the claim can be the same or can be different for the E/M service. 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.
What kind of documentation does Medicare require in the record in order to append modifier 25 to the claim?
According to the Medicare Claims Processing Manual, “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 at the following web link: Medicare Claims Processing Manual, Chapter 12, Section 30.6.6.
If a problem is noted on the day of a minor procedure which requires no additional work by the physician, can an E/M be reported with modifier 25?
By the very definition of the modifier, the additional E/M 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. More information is available in the NCCI Policy Manual (Chapter I, Section E), which can be accessed from the following CMS web link: National Correct Coding Initiative Edits.
Can I use modifier 57 (decision for surgery) instead of modifier 25 when I perform an E/M on the same day as a minor procedure?
According to the Medicare Learning Network® publication titled Global Surgery Fact Sheet, “The modifier 57 is not used with minor surgeries because the global period for minor surgeries does not include the day prior to surgery. When the decision to perform the minor procedure is typically done immediately before the service, it is considered a routine pre-operative service and a visit or consultation is not billed in addition to the procedure. MACs may not pay for an E/M service billed with the CPT® modifier 57 if it was provided on the day of or the day before a procedure with a 0 or 10 day global surgical period.” To view more information, select this web link: Global Surgery Fact Sheet (ICN 907166).
Are global period assignments limited to surgical procedures?
Some non-surgical procedures carry global periods as well. Examples of non-surgical procedures with 000 global days assigned would be chiropractic manipulative treatment (CPT® codes 98940-98942) and osteopathic manipulative therapy (CPT® codes 98925-98929). An example of a non-surgical procedure with a 090 day global assignment would be intracavitary radiation source application, simple (CPT® code 77761). To review more details about global periods, select the following web link: Medicare Claims Processing Manual, Chapter 12, Section 40.
Is the global surgery payment restricted to a certain place of service or setting?
Global surgery applies to any setting according to the Medicare Learning Network®publication. This would include inpatient or outpatient hospital settings, ambulatory surgery centers as well as physicians’ offices. Visits to a patient in an intensive care or critical care unit are included in the global surgical package if a surgeon visits the patient in that setting after a procedure. For more information, select the following link: Global Surgery Fact Sheet.
Where can providers find more information about global periods?
Providers can find additional information about global periods in Chapter 12 of the Medicare Claims Processing Manual. Section 30.6.6 covers payment for E/M services provided during the global period of surgery. Section 40 covers surgeons and global surgery. Section 40.1 defines the global surgical package and includes components of a global surgical package and also defines services that are not included in the global surgical package. To review more about global periods, please refer to the following web link: Medicare Claims Processing Manual, Chapter 12 (Sections 30, 40).
How are the peers defined?
A single rendering provider was identified by National Provider Identifier (NPI). For this CBR, each provider is compared to two peer groups:
- State: All rendering Medicare Part B providers practicing in the provider’s state with allowed charges for E/M using specialty code 07 (dermatology)
- National: All rendering Medicare Part B providers in the nation with allowed charges for E/M using specialty code 07 (dermatology)
How were claims selected for review for CBR201708?
We analyzed data for approximately 11,000 fee-for-service Medicare Part B providers. These providers were identified by Rendering NPI. Claims with CPT® codes 99211-99215 for providers with specialty code (07) dermatology were pulled on July 11, 2017 from the Integrated Data Repository (IDR). The claim lines used in this analysis cover dates of service between April 1, 2016 and March 31, 2017. If you would like more information about the IDR, select the following web link: CMS Integrated Data Repository (IDR).
What is a Visit?
For the purposes of this CBR, a visit is defined as a single date of service by a beneficiary with a rendering provider. For example, if a beneficiary had one service of CPT® 99211 and one service of CPT® 99212 on the same date with the same provider, both services would be considered as the same visit.
What do the comparisons mean?
There are four possible outcomes for the comparisons between the provider and the peer groups:
- Significantly Higher – the provider’s value is higher than the peer value and the statistical test confirms significance
- Higher – the provider’s value is higher than the peer value, but the statistical test does not confirm significance
- Does Not Exceed – the provider’s value is not higher than the peer value
- N/A (not applicable) – the provider did not have sufficient data for comparison
What does Table 1 mean?
Table 1 is an example of the CPT® Codes included in this CBR, the Abbreviated Descriptions of the codes, and the Typical Times allowed for each type of exam. For your convenience, the sample CBR can be accessed from the following web link: CBR201708 Sample CBR.
What’s the significance of Table 2?
Table 2 is titled Summary of Your Utilization of E/M Codes and Modifier 25. It’s an example of a mock provider’s utilization of the CPT® codes with and without modifier 25. Table 2 lists the CPT® Code, the Type of modifier appended, the provider’s total Allowed Charges, the total Allowed Services, the total Visit Count, and the total distinct Beneficiary Count. The Total row shows the sum for all of the CPT® codes with and without modifier 25. To view the sample of Table 2, select the following web link: CBR201708 Sample CBR.
How do you explain Table 3?
Table 3 shows the individual provider’s Percentage of Services Appended with Modifier 25. It is calculated as the Number of Services with Modifier 25 divided by the Total Number of Services, and then divided by 100. To view the sample of Table 3 and results for each state and the nation, select the following web links:
What does Table 4 show?
Table 4 shows the individual provider’s Average Minutes per Visit with Modifier 25 and without Modifier 25. To calculate this metric, the Total E/M Weighted Services by Modifier Designation is first calculated by using the typical times denoted in Table 1. This value is then divided by the Total Number of E/M Visits by Modifier Designation. Please select the following links to view a sample of Table 4 and the results for each state and the nation:
What is the meaning of Table 5?
Table 5 gives the individual provider’s Average Allowed Charges per Beneficiary. An illustration is available at CBR201708 Sample CBR. The average is calculated as the Total Allowed Charges divided by the Total Number of Beneficiaries. Results for each state and the nation can be viewed at CBR201708 Statistical Debriefing.