Corporate Compliance

Tip: Keep in compliance with modifier -25

Compliance Monitor, March 28, 2007

Keep the following tips in mind to properly assign modifier -25 and remain in compliance:

Use caution before accepting suppliers' recommendations on billing criteria. William Malm, ND, RN, president of Health Revenue Integrity Services in Cleveland, OH, says many medical device or supplies dealers issue specific coding/billing advice, which may include guidance on billing their products in conjunction with an E/M level and modifier -25. Malm warns that this advice is not source information (such as that provided by CMS or an FI), and therefore, you should not let it affect your facility's policy for reporting modifier -25.

Eliminate negative "patterns of behavior" with modifier -25. The OIG won't be as concerned with individual claims as it is with a routine and continuous pattern of improper billing--e.g., hard-coding modifier -25 into your chargemaster and assigning an E/M level to every clinic visit, Malm explains. He advises against hard-coding modifier -25 into chargemasters for this reason.

Review the official transmittals with modifier -25 guidance, particularly Transmittal A-00-40, "Further Information on the Use of Modifier -25 in Reporting Hospital Outpatient Services"; and Transmittal A-01-80, "Use of Modifier -25 and Modifier -27 in the Hospital OPPS." Make sure your coding staff is grounded in the guidelines and follows them. "Hospitals may also find Medicare Claims Processing Manual, chapter 12, section c, "Minor surgeries and endoscopies" instructive, even though that section is really directed towards physician billing," says Hugh Aaron, MHA, JD, CPC, CPC-H, senior vice president for compliance and regulatory affairs/regulatory counsel for HCPro, Inc., in Marblehead, MA.

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