Health Information Management

Tip: Steps to account for appropriate modifier -25 usage

APCs Insider, July 31, 2015

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Providers should look at their existing procedure charges and make sure they have built some dollars into the charge for the E/M-type services that occur on the day of a scheduled procedure. This is for nursing resources and overhead costs that are not considered separate and distinct and would not warrant reporting an E/M visit with modifier -25 (significant, separately identifiable E/M service by the same physician or other qualified healthcare professional on the same day of the procedure or other service).
CMS has stated repeatedly that the OPPS is moving toward bigger bundles, and the more bundling that occurs, the more providers have to make sure they're accounting for all of the resources they're using.
Providers should also examine how they schedule services and what level of documentation they have in their records to support the use of modifier -25. When it's warranted because a separate E/M service was provided, it should be used so that revenue is not being lost.
Facilities may need to provide refresher education and a training course with case examples so that everyone can better understand when to charge separately for an E/M visit on the same date of service as a procedure, and what level of documentation must be present in the record.
This tip is adapted from “Providers continue to grapple with reporting modifier -25" in the July issue of Briefings on APCs.

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