Modifier 25 E/M: Ball of Confusion

For the past 20 years, the most asked question from all of my readers is--what documentation do I need to justify a separate visit with drug admin or with a minor procedure? I am not an expert on minor procedures, but with drug admin, the origin of the Modifier 25 requirement was when CMS decided to no longer allow a 99211 to be coded with it. The Medicare national average value of the Work Relative Values in 96365, for example, is $6.79. That does not imply much professional time (or even staff time, for that matter). Still, I have folks saying that all visits are bundled in and that the patients must be seen on a different day. EEEEK!

Here are some things to be aware of (denial rates based on our claims data in focalPoint®):

• Most of the time, large payers DO NOT deny claims for E/M visits on the date of drug admin. Traditional Medicare has a less than 5% denial rate; CVS/AETNA is 5.28%; United is 7.46%; Humana is 9.36%; and CIGNA is 9.92%. The denial average for all drugs in our database is 10%, plus these denials may be unrelated to the E/M.
• BUT, some of the smaller payers and Medicaid programs do have high denial rates. Most of them involve record requests, but a few payers bundle visits.
• There is no such thing as a "chair visit". The patient should be seen in an exam room like any other E/M service, and documentation must follow CPT guidelines.
• The Chief Complaint 'follow up' does not denote the necessity for a separately identifiable visit. And, even worse, a note stating that the patient is in for an infusion of XYZ drug does not help your case at all if a record is requested. The coding guideline states that a different diagnosis is not necessary, but linking the visit to Z51.11 (Encounter for Chemo) is a huge no-no.
• Appeal denials if medical necessity holds up in your documentation. While payers may want to bundle visits, that is not the CPT Guideline. It just says that the E/M must be separately identifiable--not exactly clear, but a separate note, separate session, and a separate diagnosis from the drug admin (not necessarily the drug) certainly help.

While most of the guidance (including the Medicare Claims Processing Manual) is vague, Noridian's guidance is confusing many people because it implies that you need a different diagnosis. It is also not the same as the CPT guidance.

Here it is (highlights mine):

"It may be appropriate to append modifier 25 to an E/M service when a separately identifiable, medically necessary service has been provided in addition to a procedure provided on the same date. The physician/NPP's documentation must indicate that on the day a procedure (identified by a CPT code) was performed, the patient's condition required a significant, separately identifiable E/M service. Typically, an "interval history" with pertinent, focused exam is already a portion of the pre-service work of performing any procedure and not separately billable. In contrast, a separately billable E/M service does not relate directly to the actual performance of the procedure. This circumstance may be reported by appending modifier 25 to the appropriate level of the follow-up E/M service. Commonly, the separately identifiable nature of a service is indicated by a separate diagnosis code. Rarely, an E/M service separate from the procedure may be associated with the same diagnosis code.

Examples of Billing E/M Services with Modifier 25 (not an all inclusive list)

• It is not appropriate to append modifier 25 to an E/M service for use of a room, technician time, nursing care, assessment, or monitoring, nor for the routine "interval history" of "is everything OK" since the last visit/treatment when there is no other more significant service.
• Example: The patient arrives for chemotherapy treatment. The nurse completes an assessment, including vital signs, confirms there are no new or interval issues, starts the treatment, and continues to monitor the patient during the treatment periodically. A separately identifiable E/M service has not been provided and should not be billed with modifier 25.
• It is appropriate to append modifier 25 to an E/M service billed on the same day as a drug administration code when documentation clearly supports a medically necessary E/M service unrelated to the chemotherapy administration. This may include physician/NPP evaluation and management of the disease process, requiring the administration of the drug if an alteration of the treatment plan may be required due to symptoms/signs, adverse treatment reactions, etc. A routine interval evaluation, for example, to assure there are no new issues when the patient presents for chemotherapy, may not be separately paid by Medicare and must not be billed.
• Example: The patient arrives for chemotherapy treatment, newly refusing to continue home medication regimen due to side effects. The physician/NPP evaluates the patient complaint and makes a determination on potential changes in the treatment plan. The patient also receives chemotherapy. In addition to the administration of the chemotherapy, the modifier 25 may be appended to the physician /NPP-submitted E/M service.

However, a Medicare Coverage Article clearly does not state this:

Reporting Evaluation and Management (E/M) Visit on the Same Day as Drug Administration Services

The E/M service for CPT code 99211 cannot be paid if it is billed with a drug administration service. This includes a chemotherapy or nonchemotherapy drug infusion service, as well as a therapeutic or diagnostic injection code.

When a medically necessary, significant, and separately identifiable E/M service (which meets a higher complexity level than CPT code 99211) is performed, in addition to drug administration service(s), the appropriate E/M CPT code should be reported with modifier -25. Documentation should support the level of E/M service billed. For an E/M service provided on the same day, a different diagnosis is not required.

Please refer to the CMS IOM Publication 100-04, Chapter 12, Sections 20.3.B, 30.5.C, D, F, 30.6.6 and 30.6.7.D for additional information on E/M services furnished on the same day as drug administration services.

Again, payment of $6.79 does not encompass the work of the physician to ensure that the patient is responding to the prescribed treatment; complying with their treatment at home; and not experiencing side effects or new disease problems.

The history of why an E/M can be billed separately is outlined in this ancient letter. Sometimes, the oldies truly are goodies.