Usage of Modifier 25 vs 57

Modifier 25 

 

Significant, separately identifiable evaluation and management [E/M] service by the same physician or Other Qualified Health Care Professional on the same day of the service 

Modifier 25 is appended to an E&M service, when performed 0 days and or 10 days global period - (never to a procedure) 

 

Example 1:  

 

A patient visits the cardiologist for an appointment complaining of occasional chest discomfort during exercise. The patient has a history of hypertension and high cholesterol. After the physician completes an office visit it is determined that the patient needs a cardiovascular stress test that is performed on same day by the same physician. 

The physician codes an E/M visit (99201 – 99215) and he also codes for the cardiovascular stress test (93015). The modifier 25 is added to the E/M visit to indicate that there was a separately identifiable E/M on the same day of a procedure. 

The modifier stops the bundling of the E/M visit into the procedure. When reviewing the physician’s documentation, the carrier should be able to determine that both the E/M and the procedure were medically necessary. As always, the documentation has to support the claim that sends to the carrier if required. 

 

Examples of when Not to Use Modifier 25 

 

Do not use a 25 modifier when billing for services performed during a postoperative period if related to the previous surgery. 

Do not append modifier 25 if there is only an E/M service performed during the office visit (no procedure done). 

Do not use a modifier 25 on any E/M on the day a “Major” (90 day global) procedure is being performed. 

Do not append modifier 25 to an E/M service when a minimal procedure is performed on the same day unless the level of service can be supported as significant, separately identifiable. All procedures have “inherent” E/M service included. See example #2. 

Patient came in for a scheduled procedure only – Do not code E/M service. 

 

Modifier 57 

 

Modifier 57 is an “Decision for Surgery”, Modifier 57 should only be appended to E/M codes. 

Difference between for modifier 25 vs modifier 57, 

• Modifier 25 - Use modifier -25 on an E/M service provided on the same day as a minor procedure 
• Modifier 57 - Append modifier -57 to any E/M service on the day of or the day before a major surgical procedure when the E/M service results in the decision to go to surgery 

Major surgery includes all surgical procedures assigned a 90-day global surgery period. 

Append, only to the E/M procedure code, where the decision to perform surgery is made the day of or day before a major surgery during an E/M service. 

 

Inappropriate Uses 

 

• Appending to a surgical procedure code.
• Appending to an E/M procedure code performed the same day as a minor surgery. 
• When the decision to perform a minor procedure is done immediately before the service, it is considered a routine preoperative service and not billable in addition to the procedure.
• Do not report on the day of surgery for a pre-planned or pre-scheduled surgery. 
• Do not report on the day of surgery if the surgical procedure indicates performance in multiple sessions or stages. 

 

Guidelines: 

 

• Global period includes, 
• Day before surgery 
• Day of the surgery; and 
• Number of days following the surgery 

E/M service resulting in initial decision to perform major surgery is furnished during post-operative period of another unrelated procedure, then the E/M service must be billed with both the 24 and 57 modifiers 

Note: A major surgery has a 90-day post-operative period and a minor surgery has either a zero or a 10-day post-operative period. 

 

Example 1 

 

A surgeon seeing the patient in the emergency department, then performs CPT code 65285 repair of laceration; cornea and/or sclera, perforating, with reposition or resection of uveal tissue on the same day. Since this surgical code has a 90-day global period, the correct way to bill the E/M for separate, appropriate payment is 99284-57 emergency department visit for the evaluation and management of a patient; 65285. 

 

Example 2 

 

The patient came for ED and presents with Chest Pain, Lightheadedness and palpitation on Dec 26th. And called as Cardiology consult, He is evaluated the patient and diagnosed as complete Heart Block, Coronary Artery disease. Due to the severity of the patient’s condition, the decision was made to implant Dual Chamber permanent pacemaker on tomorrow, after diagnostic testing was completed on the same date. The patient was admitted to the hospital on the same day; the claim for hospital admission was submitted with CPT code 99221 and consult document supported to bill CPT 99255. 

• Admit – 99221 
• Consult – 99255 - 57 
• Pacemaker - 33208 

Return to check modifier 24 & 59

COVID-19 news National public health emergency extended to July 19, 2021

The national public health emergency has been extended from April 20, 2021, to July 19, 2021. Below is an overview of how that extension affects temporary provisions for COVID-19 testing and testing-related services for major payers

UHC

Individual Exchange, Individual and Group Market health plans: From Feb. 4, 2020 through the national public health emergency period, UnitedHealthcare is waiving cost sharing for in-network and out-of-network COVID-19 tests and testing-related services, including testing-related telehealth visits.

Medicare Advantage: From Feb. 4, 2020 through the national public health emergency period, UnitedHealthcare is waiving cost sharing for in-network and out-of-network tests for COVID-19.

Medicaid: State-specific rules and other state regulations may apply. For Medicaid and other state-specific regulations, please refer to your state-specific website or your state’s UnitedHealthcare Community Plan website, if applicable.

 

Aetna

Aetna’s liberalized coverage of Commercial telemedicine services, as described in its telemedicine policy, will continue until further notice

For Individual Aetna Medicare Advantage members, copays are waived for in-network telehealth visits for primary care through the end of the Public Health Emergency.

Cigna

The cost-share waiver for COVID-19 diagnostic testing and related office visits is in place until the end of Public Health Emergency (PHE) period said by Cigna

Interim accommodations for credentialing are extended through the end of the public health emergency period, currently through April 20, 2021

Humana

To support providers with caring for their Humana patients while promoting both patient and provider safety, we have updated our existing telehealth policy for the duration of the COVID-19 public health emergency (PHE)

Temporary expansion of telehealth service scope and reimbursement rules

To ease systemic burdens arising from COVID-19 and support shelter-in-place orders, Humana is encouraging the use of telehealth services to care for its members. 

Please refer to CMS, state and plan coverage guidelines for additional information regarding services that can be delivered via telehealth

Prolonged Service Office or Other Outpatient Services 99417 & G2212

Prolonged Service

Use 99417 & G2212 in conjunction with 99205, 99215 and do not report 99417 on the same date of service as 99354, 99355, 99358, 99359, 99415, 99416

Do not report 99417 for any time unit less than 15 minutes. 

The payers will not reimburse you unless you report it with an appropriate primary code because this code is an add–on code, 

Confirm payer coverage and requirements for this code.

• Medicare requires this code G2212 in place of +99417.
• Private payers require this code 99417 in place of G2212

As an example of proper use, when coding based on time, you report 99205 for a new patient visit lasting 60 to 74 minutes. Once the time reaches 89 minutes, you also may report +G2212 because 89 minutes is 15 minutes beyond the maximum required time of 74 minutes.

When coding based on time, you report 99205 for a new patient visit lasting 60 to 74 minutes. Once the time reaches 75 minutes, you also may report +99417 because 75 minutes is 15 minutes beyond the minimum required time of 60 minutes.

When coding based on time, you report 99215 for an established patient visit lasting 40 to 54 minutes. Once the time reaches 55 minutes, you also may report +99417 because 75 minutes is 15 minutes beyond the minimum required time of 60 minutes.

Total Duration of New Patient Office or Other Outpatient Services (use with 99205)	Code(s)
less than 75 minutes	Not reported separately
75-89 minutes	99205 X 1 and 99417 X 1
90-104 minutes	99205 X 1 and 99417 X 2
105 minutes or more	99205 X 1 and 99417 X 3 or more for each additional 15 minutes
Total Duration of Established Patient Office or Other Outpatient Services (use with 99215)	Code(s)
less than 55 minutes	Not reported separately
55-69 minutes	99215 X 1 and 99417 X 1
70-84 minutes	99215 X 1 and 99417 X 2
85 minutes or more	99215 X 1 and 99417 X 3 or more for each additional 15 minutes

Summary of Evaluation and Management Changes 2021

 The AMA conducted a peer-reviewed study to determine the amount of time that could be saved after CMS’ changes for E/M encounters are fully implemented. 

They found that the changes would bring a conservative reduction of 2.11 minutes per visit. Assuming a physician sees 20 patients per day, physicians would gain about 42 minutes a day to focus on patient care.

• Reduce administrative burden on documentation and coding
• Reduce the need for audits by adding and expanding key definitions and guidelines
• Reduce documentation in the medical record that is not needed for patient care
• Keep payment for E/M resource-based and eliminate the need to redistribute payments between specialties
• Deletion of level outpatient visit CPT code 99201

Summary of Revision E&M 2021

 

Eliminate documentation of the history and physical exam as components for E/M code selection, however, AMA asked the providers should continue the documentation part of the history and physical exam in order to evaluate the patient's care and conditions.

Office and other outpatient services include a medically appropriate history and/or physical examination when performed. The provider determines the nature and extent of the history and/or exam required. The extent of history and exam do not affect code selection for E/M codes 99202–99215. However, all services performed should be documented appropriately in the medical record.

The physicians can select the E/M level based on the MDM or on total time.

 

MEDICAL DECISION MAKING

 

The three elements of MDM is important to select the level

• The complexity of the patient’s presenting problem, 
• Data to be reviewed, 
• Risk is not materially changed, but the work-group did extensively edit and clarify definitions in the E/M guidelines 

Time

 

Time is defined as MINIMUM TIME, not typical time, and is measured as the total time the physician or other qualified healthcare professional spends on the date of service. 

• Face-to-face and
• Non-face-to-face time

This includes time in activities that require the physician or QHP and does not include time in activities normally performed by clinical staff.

The time calculation would be considered as physician/other qualified health care professional spends time on the day of the encounter includes the following activities when performed,

• Preparing to see the patient (e.g., review of tests)
• Obtaining and/or reviewing the separately obtained history
• Performing a medically appropriate examination and/or evaluation
• Counseling and educating the patient/family/caregiver
• Ordering medications, tests, or procedures
• Referring and communicating with other health care professionals  (when not separately reported)
• Documenting clinical information in the electronic or other health records
• Independently interpreting results (not separately reported)  and communicating results to the patient/family/caregiver
• Care coordination (not separately reported)

Prolonged Service

 

Use 99417 & G2212 in conjunction with 99205, 99215 and do not report 99417 on the same date of service as 99354, 99355, 99358, 99359, 99415, 99416

Do not report 99417 for any time unit less than 15 minutes. 

The payers will not reimburse you unless you report it with an appropriate primary code because this code is an add–on code, 

Confirm payer coverage and requirements for this code.

• Medicare requires this code G2212 in place of +99417.
• Private payers require this code 99417 in place of G2212

As an example of proper use, when coding based on time, you report 99205 for a new patient visit lasting 60 to 74 minutes. Once the time reaches 89 minutes, you also may report +G2212 because 89 minutes is 15 minutes beyond the maximum required time of 74 minutes.

When coding based on time, you report 99205 for a new patient visit lasting 60 to 74 minutes. Once the time reaches 75 minutes, you also may report +99417 because 75 minutes is 15 minutes beyond the minimum required time of 60 minutes.

When coding based on time, you report 99215 for an established patient visit lasting 40 to 54 minutes. Once the time reaches 55 minutes, you also may report +99417 because 75 minutes is 15 minutes beyond the minimum required time of 60 minutes.

Total Duration of New Patient Office or Other Outpatient Services (use with 99205)	Code(s)
less than 75 minutes	Not reported separately
75-89 minutes	99205 X 1 and 99417 X 1
90-104 minutes	99205 X 1 and 99417 X 2
105 minutes or more	99205 X 1 and 99417 X 3 or more for each additional 15 minutes
Total Duration of Established Patient Office or Other Outpatient Services (use with 99215)	Code(s)
less than 55 minutes	Not reported separately
55-69 minutes	99215 X 1 and 99417 X 1
70-84 minutes	99215 X 1 and 99417 X 2
85 minutes or more	99215 X 1 and 99417 X 3 or more for each additional 15 minutes

Repayment of COVID-19 Accelerated and Advance Payments

All Medicare providers and suppliers who requested and received CAAPs that we began recovering those payments as early as March 30, 2021, depending upon the 1 year anniversary of when you received your first payment. 

It also gives information on how to identify recovered payments. 

Title V (Section 2501) of the Continuing Appropriations Act, 2021 and Other Extensions Act, enacted on October 1, 2020, amended the CAAP repayment terms for all providers and suppliers who requested and received CAAPs during the COVID-19 PHE and established a lower interest rate of 4% for any demanded overpayments to recover CAAP balances due. 

The CAAP repayment terms provide as follows,

• Repayment begins 1 year starting from the date we issued your first CAAP.

• Beginning 1 year from the date we issued the CAAP and continuing for 11 months, we’ll recover the CAAP from Medicare payments due to providers and suppliers at a rate of 25%.

• After the end of this 11 month period, we’ll continue to recover the remaining CAAP from Medicare payments due to providers and suppliers at a rate of 50% for 6 months.

• After the end of the 6 month period, your Medicare Administrative Contractor (MAC) will issue you a demand letter for full repayment of any remaining balance of the CAAP. 

• If we don’t receive a payment within 30 days, interest will accrue at the rate of 4% from the date your MAC issues you the demand letter. 

• After that, we’ll assess interest for each full 30-day period that you fail to repay the balance.

If you received an accelerated or advance payment, CMS will begin to recoup any outstanding balance from any payments due to you from your Medicare claims. 

This began as soon as March 30, 2021, depending upon the 1 year anniversary of when you received your first payment

Five New Vaccine Codes Released - Effective July 1,2021

The CPT Editorial Panel has released early an additional five new codes in the Medicine/Vaccine, Toxoids section of the AMA’s CPT Codes. 

The following codes are effective from July 1, 2021, but won’t be published until CPT 2022,

• 90626 Tick-borne encephalitis virus vaccine, inactivated; 0.25 mL dosage, for intramuscular use
• 90627 Tick-borne encephalitis virus vaccine, inactivated; 0.5 mL dosage, for intramuscular use
• 90671 Pneumococcal conjugate vaccine, 15 valent (PCV15), for intramuscular use
• 90677 Pneumococcal conjugate vaccine, 20 valent (PCV20), for intramuscular use
• 90758 Zaire ebolavirus vaccine, live, for intramuscular use

These codes will be listed out of sequence. Medicare coverage will be determined by the Centers for Medicare & Medicaid Services in future rulemaking.

Click Here to refer COVID-19 Lab Codes

Billin Guidelines for Depression Screening

Reimbursement Guidelines for Depression Screening - CPT G0444

Depression screening CPT G0444 can't be coded with CPT G0402 & G0438 but you may report with CPT G0439. NCCI edits stated as "Code G0444 is a column 2 code for G0402. You may not override the edit".

Details of the CPTs,

• G0444 - Annual depression screening, 15 minutes
• G0402 - Initial preventive physical examination; face-to-face visit, services limited to new beneficiary during the first 12 months of Medicare enrollment
• G0438 - Annual wellness visit; includes a personalized prevention plan of service (PPPS), initial visit

Nationally Covered Indications:

CMS will cover annual screening up to 15 minutes for Medicare beneficiaries when staff-assisted depression care supports are in place to assure accurate diagnosis, effective treatment, and follow-up. 

At a minimum level, staff assisted supports consist of clinical staff (e.g., physician assistant, nurse) in the primary care setting who can advise the physician of screening results and who can facilitate and coordinate referrals to mental health treatment. Services covered under this NCD must be provided by a primary care provider.

Nationally Non-Covered Indications:

Screening for depression is non-covered when performed more than one time in a 12-month period. Also self-help materials, telephone calls, and web-based counseling are not separately reimbursable by Medicare and are not part of this NCD.

Medicare coinsurance and Part B deductible are waived for this preventive service.

Covered ICD Codes:

 

The specified below ICD codes are covered for depression screening services and may not be limited and some private payers have specific guidelines,

• F06.0 Psychotic disorder with hallucinations due to known physiological condition
• F06.2 Psychotic disorder with delusions due to known physiological condition
• F06.30 Mood disorder due to known physiological condition, unspecified
• F06.31 Mood disorder due to known physiological condition with depressive features
• F06.32 Mood disorder due to known physiological condition with major depressive-like episode
• F06.33 Mood disorder due to known physiological condition with manic features
• F06.34 Mood disorder due to known physiological condition with mixed features
• F06.4 Anxiety disorder due to known physiological condition
• F06.8 Other specified mental disorders due to known physiological condition
• F07.0 Personality change due to known physiological condition
• F07.89 Other personality and behavioral disorders due to known physiological condition
• F07.9 Unspecified personality and behavioral disorder due to known physiological condition
• F09 Unspecified mental disorder due to known physiological condition
• F32.0 Major depressive disorder, single episode, mild
• F32.1 Major depressive disorder, single episode, moderate
• F32.2 Major depressive disorder, single episode, severe without psychotic features
• F32.3 Major depressive disorder, single episode, severe with psychotic features
• F32.4 Major depressive disorder, single episode, in partial remission
• F32.5 Major depressive disorder, single episode, in full remission
• F32.81 Premenstrual dysphoric disorder
• F32.89 Other specified depressive episodes
• F32.9 Major depressive disorder, single episode, unspecified
• F32.A Depression, unspecified
• F33.0 Major depressive disorder, recurrent, mild
• F33.1 Major depressive disorder, recurrent, moderate
• F33.2 Major depressive disorder, recurrent severe without psychotic features
• F33.3 Major depressive disorder, recurrent, severe with psychotic symptoms
• F33.40 Major depressive disorder, recurrent, in remission, unspecified
• F33.41 Major depressive disorder, recurrent, in partial remission
• F33.42 Major depressive disorder, recurrent, in full remission
• F33.8 Other recurrent depressive disorders
• F33.9 Major depressive disorder, recurrent, unspecified
• F43.21 Adjustment disorder with depressed mood
• F43.22 Adjustment disorder with anxiety
• F43.23 Adjustment disorder with mixed anxiety and depressed mood
• F43.24 Adjustment disorder with disturbance of conduct
• F43.25 Adjustment disorder with mixed disturbance of emotions and conduct
• F43.29 Adjustment disorder with other symptoms
• F53.0 Postpartum depression
• F53.1 Puerperal psychosis
• F68.A Factitious disorder imposed on another
• R45.88 Nonsuicidal self-harm
• Z13.31 Encounter for screening for depression
• Z13.32 Encounter for screening for maternal depression
• Z13.39 Encounter for screening examination for other mental health and behavioral disorders
  

 

Place Of Service:

Effective for claims with dates of service on and after April 2, 2012, contractors shall pay for annual depression screening claims, G0444, only when services are provided at the following Places of Service (POS)

• 11 Physician’s office
• 19 Off Campus-Outpatient hospital
• 22 On Campus-Outpatient hospital
• 49 Independent clinic 
• 71 State or local public health clinic