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MIR-2006-7AB, July 2006
MLN Matters. . .Information for Medicare Providers
(Issued by the Centers for Medicare & Medicaid Services)
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Payment for Evaluation and Management Services Provided During Global Period of Surgery
Provider Types Affected
Physicians and qualified non-physician practitioners (NPP) who bill Medicare carriers for their services
Key Points
- The Centers for Medicare & Medicaid Services (CMS) has clarified the documentation requirements and policy requirements for the use of CPT modifier -25 used with E/M services. Please refer to the manual attachment to CR5025, the Medicare Claims Processing Manual, Publication 100-04, Chapter 12, Section 30.6.6, for revisions regarding the use of CPT modifier -25.
- Physicians and qualified non-physician practitioners (NPP) should use CPT modifier -25 to designate a significant, separately identifiable E/M service provided by the same physician/qualified NPP to the same patient on the same day as another procedure or other service with a global fee period.
- Common Procedural Terminology (CPT) modifier -25 identifies a significant, separately identifiable evaluation and management
(E/M) service. It should be used when the
E/M service is above and beyond the usual pre- and postoperative work of a procedure with a global fee period performed on the same day as the E/M service.
- Different diagnoses are not required for reporting the E/M service on the same date as the procedure or other service with a global fee period. Modifier -25 is added to the E/M code on the claim.
- Both the medically necessary E/M service and the procedure must be appropriately and sufficiently documented by the physician or qualified NPP in the patient’s medical record to support the need for Modifier -25 on the claim for these services, even though the documentation is not required to be submitted with the claim.
- Your carrier will not retract payment for claims already paid or retroactively pay claims processed prior to the implementation of CR5025. But, they will adjust claims brought to their attention.
- Carriers will not pay for an E/M service reported with a procedure having a global fee period unless CPT modifier -25 is appended to the E/M service to designate it as a significant and separately identifiable E/M service from the procedure. Such payment will be denied with the following messages:
Claim Adjustment Reason Code
- 97 - Payment is included in the allowance for another service/procedure.
Remittance Advice Remark Code
- M144 - Pre-/postoperative care payment is included in the allowance for the surgery/procedure.
Additional Information
CR1250, Transmittal A-00-40, July 20, 2000, Further Information on the Use of Modifier -25 in Reporting Hospital Outpatient Services, can be found at http://www.cms.hhs.gov/transmittals/downloads/A0040.pdf  on the CMS Web site. This article provides information that is especially helpful for emergency department use of modifier -25.
CR1725, Transmittal A-01-80, June 29, 2001, Use of Modifier -25 and Modifier -27 in the Hospital Outpatient Prospective Payment System (OPPS), can be found at http://www.cms.hhs.gov/Transmittals/Downloads/A0180.pdf on the CMS Web site.
CR5025 is the official instruction issued to your carrier regarding changes mentioned in this article, MM5025. CR 5025 may be found by going to http://www.cms.hhs.gov/Transmittals/downloads/R954CP.pdf on the CMS Web site.
Please refer to your local carrier if you have questions about this issue. To find your carrier’s toll-free phone number, go to http://www.cms.hhs.gov/MLNProducts/downloads/CallCenterTollNumDirectory.pdf on the CMS Web site.
Disclaimer
This article was prepared as a service to the public and is not intended to grant rights or impose obligations. This article may contain references or links to statutes, regulations, or other policy materials. The information provided is only intended to be a general summary. It is not intended to take the place of either the written law or regulations. We encourage readers to review the specific statutes, regulations and other interpretive materials for a full and accurate statement of their contents.
MLN Matters Number: MM5025
Related Change Request (CR) #: 5025
Related CR Release Date: May 19, 2006
Effective Date: June 1, 2006
Related CR Transmittal #: R954CP
Implementation Date: August 20, 2006
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