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May 14, 2012

Modifier-25 Use with "XXX" Surgery Codes

CGS Administrators has recently received a large volume of questions regarding the use of modifier-25 with CPT codes having a global surgery indicator of "XXX" (for example: injection and infusion codes). Payment for a service with an "XXX" indicator already includes the E&M component required to provide the service. The National Correct Coding Initiative states: Payment for XXX procedures performed by physicians include the inherent pre-procedure, intra-procedure, and post-procedure work usually performed each time the procedure is completed.

This work should never be reported as a separate E&M code. Other "XXX" procedures are not usually performed by a physician and have no physician work relative value units associated with them. A physician should never report a separate E&M code with these procedures for the supervision of others performing the procedure or for the interpretation of the procedure."

Based on the definition of modifier-25; the only time an E&M service would be appropriate with an XXX procedure is if the E&M is significant and separate from the XXX service provided on the same day. The E&M may be related to the same diagnosis prompting the XXX procedure but cannot include any work inherent in the performance, supervision or interpretation of the XXX procedure. This means payment for the work ordinarily provided by the physician or non-physician clinical staff to evaluate the patient before and after an injection/infusion service is already reflected in the fee schedule payment amount for the service. In situations where the pre/post infusion evaluation services are the only E&M component provided, no additional payment for an E&M may be made on the same date of service.

Conversely, when a separate and distinct E&M service is provided on the same date of service as an "XXX" code, modifier-25 must be appended to avoid Correct Coding Initiative (CCI) edit denials. Section 30.6.6 of Chapter 12 of the Medicare Claims Processing Manual 100-4 states:: Medicare requires that Current Procedural Terminology (CPT) modifier -25 should only be used on claims for evaluation and management (E/M) services, and only when these services are provided by the same physician (or same qualified non-physician practitioner) to the same patient on the same day as another procedure or other service. These sections of the Claims Processing Manual affirm the requirement for appending modifier-25 to an E&M code when performed on the same date of service as a "XXX" CPT code in order to receive payment for the E&M.

Circumventing the CCI edit to maximize payment; i.e. having the patient come in on another day to bill for the E&M services separately, is inappropriate and considered "unbundling" of services. This billing pattern could result in prepayment medical review and/or referral to the Zone Program Integrity Contractor

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