What is the purpose of a comparative billing report (CBR) on modifier 25 for internal medicine?
CBR201603 was created to inform internists about their billing and payment patterns on claims appended with modifier 25 for evaluation and management (E/M) for their established patients. The goal of this CBR is to assist providers with identifying and correcting billing errors. The CBR team reviewed only Fee-for-Service Medicare (Original Medicare). For more information about CBRs, please visit our website link titled, Comparative Billing Reports.
What are the Current Procedural Terminology (CPT®) codes included in this CBR?
The CPT® codes included in this CBR are:
• CPT® 99211 - Minimal Problem/Exam, 5 Minutes
• CPT® 99212 - Problem Focused/Exam, 10 Minutes
• CPT® 99213 - Expanded Problem Focused/Exam, 15 Minutes
• CPT® 99214 - Detailed Patient History/Exam, 25 Minutes
• CPT® 99215 - Comprehensive Patient History/Exam, 40 Minutes
Please refer to the CPT® 2014 and 2015 Professional Edition Manuals for complete descriptions of the CPT® codes. The manuals can be accessed from the American Medical Association (AMA) website.
How many providers received CBR201603?
CBR letters were sent to approximately 22,000 Medicare Part B providers in two separate mailings after claims data was evaluated for the CPT® codes listed above. 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 CBR, see the following link: CBR201603 Sample CBR.
Why was modifier 25 selected as a topic for a CBR?
This topic was chosen after reviewing the findings of an Office of Inspector General (OIG) report. The OIG determined that modifier 25 is an area that is vulnerable to fraud, waste and abuse. The report found that some E/M claims were billed incorrectly with modifier 25 resulting in improper payments of as much as $538 million.
What is the specific focus of CBR201603?
CBR201603 focuses on internal medicine providers who submitted claims appended with modifier 25 for E/M services for established patients. The report examines the percentage of services appended with modifier 25, the average allowed minutes per visit for claim lines with/without modifier 25 and the average allowed charges per beneficiary. To review a sample CBR of a mock provider, please visit the following link: CBR201603 Sample CBR.
Did I receive a CBR because I am billing my claims incorrectly?
No. Receiving a CBR is not necessarily indicative of incorrect billing; however, it does mean that your billing is different from your peers. There can be many reasons for different billing patterns that may not be evident from the claims data that we reviewed. Patterns can vary because of the 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.
Will providers be audited based on the results of the CBR?
The CBR team does not perform any audits, and receiving a CBR letter is not punitive in any way. Additionally, we do not have access to nor review medical records. The purpose of the CBR is to allow a provider to compare his/her billing patterns to those of his/her peers. It may be beneficial, however, 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.
Where can I find references and resources about modifier 25?
Additional information about modifier 25 is available on our CBR website. We also offer descriptions of the Tables used in this CBR at the following link: CBR201603 Statistical Debriefing.
What is a modifier?
A modifier is a two-digit value that is added to CPT® code 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 add specificity and improve the accuracy of coding. Level I modifiers are two numeric digits and are updated annually by the American Medical Association, these are the modifiers found in the CPT® manual. Level II modifiers are two digits (alpha and numeric) and are updated by CMS. A partial list of Level II modifiers can be found in the CPT® manual and a full list is found in the HCPCS level II manual.
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.
When is it appropriate to append modifier 25 to claims?
Per the National Correct Coding Initiative (NCCI) Policy Manual for Medicare Services, “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.” 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.
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.”
How can I find the global period for a 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 is accessible from the MPFSDB website page and allows you to search the following: price, payment policy indicators, relative value units (RVUs), geographic practice cost index (GPCI) and the national payment amount.
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.
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. Medicare 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, carriers do not allow separate payment for postoperative visits or services within 10 days of the surgery that are related to recovery from the procedure.”
How is the global period determined for a major surgical procedure?
Medicare has a set, approved payment amount for major procedures. A major surgical procedure includes the day before the procedure, the day of the procedure and 90 days immediately after the procedure for a total of 92 days. Per Medicare, “Major surgical procedures are determined based on the MFSDB approved amount and not on the submitted amount from the providers. The major surgery, as based on the MFSDB, may or may not be the one with the larger submitted amount.”
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
What types of services are routinely included in the global surgical package?
According to the CPT® Manual, “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.”
For more detailed information, see the CPT® 2014/2015 Professional Edition Manuals that are available from the American Medical Association (AMA) at AMA Store.
Can nonphysician practitioners use modifier 25 when billing for E/M services on the same date of service as a procedure with a global period?
Yes. According to MLN Matters®, “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.”
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.”
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 220.127.116.11 Subsection H–Reporting a Medically Necessary E/M Service Furnished During the Same Encounter as an IPPE or AWV), “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.
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.”
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 only appended 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.
How did you come up with the minutes without reviewing a patient’s chart?
The typical times (minutes) and CPT® code descriptions outlined in this CBR were taken directly from the CPT® Manuals. The minutes were not derived from patient charts, as medical records were not reviewed for our reports. We use the typical times as an estimate of the minutes to weight the services in order to measure them. To find the typical minutes for the CPT® codes, see Table 1 of the sample CBR. Typical minutes are multiplied by the total allowed services for the CPT® code in order to calculate the average allowed minutes per visit . For illustrations, please refer to Tables 1, 2 and 4 of the mock provider’s CBR on our website link: CBR201603 Sample CBR.
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 in which 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. CMS has a database that provides payment information for covered services.
My allowed charges are higher than the national averages. Are my allowed charges being compared to providers in other states that have lower allowed charges?
Medicare Physician Fee Schedule (MPFS) allowed amounts vary from area to area. While we understand that these differences may affect your average allowed charges per beneficiary, these comparisons are provided so that you may get a better idea of where you stand in comparison to the nation as a whole and to providers in your specialty. If you know that your area has higher allowed charges than the national average, then a higher average would not necessarily indicate any wrong-doing. A geographic practice cost index (GPCI) has been established to account for the variation in practice expenses across the states and nation.
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 value of 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
Can you explain what Table 1 means?
Table 1 is a list of CPT® codes, Abbreviated Descriptions and Typical Times used in this CBR. The first column lists the five CPT® codes included in this analysis. The second column provides an abbreviated description of the CPT® codes. The last column is the typical time required for the patient’s exam for each code. To review the mock provider’s sample, see the following: CBR201603 Sample CBR.
What does Table 2 mean?
Table 2 is a Summary of Your Utilization for E/M Codes and Modifier 25. To illustrate this, refer to Table 2 of the mock provider’s CBR at the following website link: CBR201603 Sample CBR. The first column lists the five CPT® codes included in this analysis. The second column, named Type, designates if the claim was submitted with or without modifier 25. The last three columns provide the total Allowed Charges, Allowed Services, and distinct Beneficiary Count for each CPT® code and type combination.
What does Table 3 mean?
Table 3 is an analysis of the Percentage of Services with Modifier 25. An illustration of Table 3 is available to reference in the mock provider’s CBR letter at the following link: CBR201603 Sample CBR. In this example, 44 percent of this provider’s services were submitted with modifier 25. The state’s and the national percentage is 21 percent for both. Therefore, this provider’s percentage is Significantly Higher than both his/her state and national peer groups, according to the results of the chi-square statistical test used in the analysis of this data. To view the results for each state and the nation, see the following link: CBR201603 Statistical Debriefing.
What does Table 4 mean?
Table 4 is an example of the Average Allowed Minutes per Visit with Modifier 25 and without Modifier 25. For an illustration, please refer to Table 4 of the mock provider’s CBR on our website link at CBR201603 Sample CBR. The averages are calculated for visits with modifier 25 and for visits without modifier 25. In this example, the provider has an average of 20.71 minutes per visit for claims submitted with modifier 25 and an average of 19.52 minutes per visit for claims submitted without modifier 25. This provider’s average allowed minutes per visit with modifier 25 is Higher than the state average of 20.15, but Does Not Exceed the national average of 21.17. This provider’s average allowed minutes per visit without modifier 25 Does Not Exceed the averages for his/her state or the nation. To review the results for each state and the nation, see the following link: CBR201603 Statistical Debriefing.
Can you explain Table 5, please?
Table 5 is an analysis of the Average Allowed Charges per Beneficiary. To illustrate Table 5, please refer to the mock provider’s sample letter at the link, CBR201603 Sample CBR. In this example, the provider’s average allowed charges per beneficiary are $404.48. The t-test confirms that the provider’s average is Significantly Higher than the state’s average of $238.96 and the nation’s average of $264.74. The results for each state and the nation can be reviewed at the following link: CBR201603 Statistical Debriefing.