You probably count on modifier 25 when you’re reporting an E/M with diagnostic endoscopic procedures like 31231 (Nasal endoscopy, diagnostic, unilateral or bilateral [separate procedure]), 92511 (Nasopharyngoscopy with endoscope [separate procedure]) or 31575 (Laryngoscopy, flexible fiberoptic; diagnostic )—but CMS could make getting reimbursed for both an E/M with a 25 modifier plus the minor procedures on the same date of service more difficult, if the 2017 Medicare Fee Schedule Proposal gets finalized.
Time to Get Nervous About Modifier 25 Use With These Codes
CMS released the proposed fee schedule on July 7, and key among the potential wrenches in the works for 2017 is a provision that would cause the agency to turn its magnifying glass to modifier 25 (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).
“Medicare claims data for CY 2015 show that 19 percent of the codes that describe 0-day global services were billed over 50 percent of the time with an E/M with Modifier 25,” CMS says in the proposed Fee Schedule. “Since routine E/M is included in the valuation of 0-day global services, we believe that the routine billing of separate E/M services may indicate a possible problem with the valuation of the bundle, which is intended to include all the routine care associated with the service.”
Due to that discovery, CMS is reviewing the CPT® codes that practices typically report with an E/M and modifier 25, and the agency has denoted 83 of them as “potentially misvalued,” meaning CMS could be considering making changes to the payment model for these codes. “We identified 0-day global codes billed with an E/M 50 percent of the time or more, on the same day of service, with the same physician and same beneficiary,” CMS said in its explanation of how it created the list of potentially misvalued codes.
31231, 92511, 31575 and More Among the 83 Codes
Of the 83 codes on the list, the following are of the most concern to otolaryngologists:
But wait—there’s more: Although the codes above are the most pressing for ENT practices, there are even more codes on the list that will impact your bottom line if CMS goes through with the proposal, including nose bleed control codes 30901-30903, biopsy codes 40490 and 69100, and mastoid cavity drainage code 69220.
Rule Could Prompt Denials If Finalized
Although it’s unclear what CMS plans to do with the 83 potentially misvalued codes on the list, the consensus is that it probably won’t be good. “It’s possible that they payers will either pay for the E/M or the procedure, but not both, requiring the practice to appeal, supplying the notes to prove the E/M was a significant, separately identifiable E/M,” says Barbara J. Cobuzzi, MBA, CPC, CENTC, COC, CPC-P, CPC-I, CPCO, vice president at Stark Coding & Consulting, LLC, in Shrewsbury, N.J.
“Denials would create two things for the payers,” Cobuzzi says. “First, some practices (about 50 percent historically) will not appeal the denials. And second, the other 50 percent will give the payers a chance to audit the documentation via the appeals and they can collect data on practice performance on the modifier 25 use and their documentation success and failure.”
The finalized fee schedule will be issued this fall, so keep an eye on Otolaryngology Coding Alert for more on this as CMS finalizes issues within the 2017 Fee Schedule.
Resource: To read the complete Proposed Fee Schedule, visit https://s3.amazonaws.com/public-inspection.federalregister.gov/2016-16097.pdf.