Health Information Management

Q&A: Why are we seeing so many edits when using modifier -25?

APCs Insider, February 13, 2015

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Q: We are seeing an increase in the number of edits we are receiving for modifier -25 (significant, separately identifiable E/M service by the same physician on the same day of the procedure or other service) on our clinic and ED visit levels. Has something changed?
 
A: Yes, status indicators changed. OCE edit 21 is defined as “medical visit on same day as a type T or S procedure without modifier -25.” In the past, services such as chest x-rays (CPT® codes 71010, 71020), insertion of urinary catheters (51702), and removal of impacted cerumen (69210) were assigned to status indicator X (ancillary services).
 
With the expanded packaging and the deletion of status indicator X under the OPPS for 2015, CMS reassigned the procedures traditionally assigned to status indicator X to status indicators Q1 (conditionally packaged) or S (significant procedure, not discounted when multiple).
 
As we know from history with the OPPS and edit 21, when a combination of status indicator S or T (significant procedure subject to multiple procedure discounting) and an E/M visit level are reported on the same date of service, the edit is triggered asking if modifier -25 is appropriate for the E/M visit level. These changes to status indicators mean that the combination of codes that will trigger edit 21 has increased.
 
Let’s use CPT code 71020 (radiologic examination, chest, 2 views, frontal and lateral) as an example. When you look at addendum B for both 2014 and 2015, the procedure is assigned status indicator Q3 (codes that may be paid through a composite APC). You then have to cross reference the CPT code in addendum M to see which APC the x-ray is assigned to when reported outside the composite. Next, you have to cross reference the APC number (0260 in this example) in addendum A to see which status indicator is assigned to the APC. For 2014, APC 0260 had a status indicator of X. For 2015, APC 0260 is assigned status indicator S.
 
The actual assignment of modifier -25 has not changed. It's still required with status indicators of S and T, but the volume of services assigned to status indicator S has increased. Continue to review the documentation for the individual encounter to ensure that appending any modifier, including modifier -25, is appropriate.
 
Editor’s note: Denise Williams, RN, CPC-H, senior vice president of revenue integrity services at Health Revenue Assurance Associates, Inc., in Plantation, Florida, answered this question.



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