by Cindy Gallee, JD, RHIA, CHC
Payers should pay particular attention to physician claims utilizing modifier 25 because this modifier is commonly misused and results in a high claim denial rate. The technical definition for modifier 25 is a significant, separately identifiable evaluation and management service by the same physician or other qualified health care professional on the same day of the procedure or other service. This modifier is used on the Evaluation and Management (E/M) code when there are other services performed on the same day that are unrelated. The other services may be a preventive medicine service or a minor surgical procedure (a procedure that has zero to ten global days in the CMS Physician Fee Schedule).The key to whether an E/M code qualifies for a 25 modifier is whether the physician’s work and documentation support the level of service represented by the E/M code in addition to the other service.
The reason for the 25 modifier is to report E/M care that is unrelated to another service, because minor procedures include pre-procedure, intra-procedure, and post-procedure work inherent in the procedure. When a separate E/M is warranted, the diagnosis code is usually, but not always, different than the diagnosis code for the other service. When supported by the documentation, a 25 modifier is present on the E/M code only, not on the minor procedure or the preventive service.
Medicare has analyzed the significant denial rate of claims with modifier 25, and, according to Part B News in their analysis of the Medicare claims data, the 15 most denied CPT/HCPCS codes then reported with modifier 25 are:
| 99201 | Office/Outpatient visit, new | 36% denial |
| G0438 | PPPS, initial visit | 23% denial |
| 99211 | Office/Outpatient visit, est | 22% denial |
| G0402 | Initial preventive exam | 19% denial |
| 99234 | Observ/Hosp same date | 16% denial |
| 99325 | Observ/Hosp same date | 15% denial |
| 99202 | Office/Outpatient visit, new | 13% denial |
| 99292 | Critical care, addl 30 min | 13% denial |
| G0439 | PPPS, subseq visit | 12% denial |
| 99342 | Home visit, new patient | 12% denial |
| 99343 | Home visit, new patient | 12% denial |
| 99305 | Nursing facility care, initial | 11% denial |
| 99354 | Prolonged service, office | 11% denial |
| 99203 | Office/Outpatient visit, new | 11% denial |
| 99220 | Initial observation care | 11% denial |
Source: DECISIONHEALTH | Part B News | January 12, 2015 | Vol. 29, Issue 2
Payers can use this information, as well as their own statistical data to isolate those E/M codes that are most likely to be inaccurate, and use this information to avoid potential reimbursement issues. Supporting documentation can be requested on a pre-adjudication basis so that suspicious claims can be investigated and denied, if necessary, prior to payment being made.
Read another FWA Brief about modifiers: Tips to Modify Your Modifier Usage: Bundling & Unbundling Compliance
Payers rely on Context4 Healthcare’s Fraud, Waste & Abuse solution. The Context4 Healthcare Fraud, Waste and Abuse (FWA) Module of FirstPassTM starts with real-time claims analysis during the adjudication cycle, while you’re still calculating your claim liability. FirstPassTM contains thousands of rules consisting of millions of editing combinations, many of which are designed to identify potential FWA conditions.
Additionally, the rules include evaluation of billed charges against our proprietary national Usual, Customary & Reasonable (UCR) fee schedule to find claims with charges out of the national norm for a service. These claims are identified and brought to your attention for follow up and compliance review. As claims are processed, the FirstPassTM FWA Module ensures that claims meet one or more of our potential FWA rules and alerts your processors to the situation so further analysis and investigations can begin.
At Context, we analyze billions of claims each year, and as part of this process we frequently find out-of-the-ordinary claim submissions that have potential for FWA activity. Utilization, regulatory, bundling, unbundling, and provider verification edits are some of the edit categories included in the FWA module.
