CMS’s Payment Policies For Modifier 25

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Modifier 25 has a long history of confusion and misuse for providers, coders, and auditors. It is one of the hardest modifiers to determine appropriate use. The term “significant, separately identifiable service” has been very subjective to different interpretations. The American Medical Association recently indicated that more than one EM service on the same day by the same provider may be reported with Modifier 25, leading to further confusion in the coding community. Modifier 25 has been on the payer’s radar for some time and continues to be a problem for payment.

Learning Objective:

• Understand the definition of significant, separately identifiable services about EM services and additional services performed on the same day.
• Identify cases where Modifier 25 is appropriate
• Reduce denials and/or compliance risks
• Reporting Modifier 25 with preventive services
• Reporting Modifier 25 with more than one EM service on the same day.
• Reporting Modifier 25 with procedures
• CMS’s policy on Modifier 25
• Correct placement of Modifier 25 when appropriately documented.

Areas Covered in the Session:

• Documentation to support the use of Modifier 25
• Techniques to identify a significant, separately identifiable service in documentation
• Services that may require the use of Modifier 25 when performed on the same day as a related EM service
• Examples of correct and incorrect use of Modifier 25 based on different specialties.
• CMS’s payment policies for Modifier 25
• Payer deviations on Modifier 25

Suggested Attendees:

• Providers
• Coders
• Office Managers
• Denial resolution teams
• Auditors
• Insurance payers
• Payment policymakers
• Billing Staff
• Coding Staff
• Compliance officers
• Clinic Managers
• Physician and Non-physician Practitioners
• Insurance Company Claims Reviewers

Presenter Biography:

Jan Rasmussen, PCS, ACS-OB, ACS-GI, – As a healthcare consultant Jan has more than 35 years of experience in physician billing, reimbursement, and compliance. Jan is currently the owner of Professional Coding Solutions, a healthcare consulting firm. She has been a Certified Professional Coder (CPC) since 1992 with active membership in the American Academy of Procedural Coders (AAPC). As a member of the AAPC, Jan previously served on their Advisory Board as the liaison to the AMA, has been a speaker for the AAPC annual conference as well as contributing to the development of AAPC’s independent study and university education programs and proficiency tests. In 1994, she was honored by AAPC as Networker of the Year. Jan was also a Regional Governor for the American College of Medical Coding Specialists (ACMCS) serving as Chair of the Ethics committee and a member of the Examination committee.

In her role as a physician consultant, she has participated in physician coding and documentation reviews including OIG government PATH and Campus audits, and designed and conducted physician coding seminars nationwide. She has been a guest speaker for several conferences sponsored by United Communications, Inc//Decision Health, AAPC as well as Coding Institute Specialty Conferences.

In previous consulting positions she was responsible for developing and conducting seminars for basic, intermediate, and advanced ICD-9-CM and CPT, teaching physician guidelines as well as special seminars for OB/Gyn, Orthopedics, Urology, Gastroenterology, General Surgery, ENT, Cardiology, Emergency Medicine and Evaluation and Management. In her role as an educator, she has been teaching E/M documentation and auditing to both physician and coding audiences since 1992 when RBRVS was first implemented.

Jan has also worked for several major health insurance payers in Wisconsin, was a coding advisor to the WPS Medicare Carrier Advisory Committee, and served as the coding and reimbursement coordinator for a 37-provider, staff model HMO clinic. As the coding and reimbursement coordinator, Jan was responsible for physician office, hospital, surgical, and nursing facility coding charge ticket development, fee development, reimbursement analysis, claims analysis, and physician education.

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