Webinar Slides

Table of Contents
Title Slides
Title Page
Disclaimer
Disclaimer Continued
Introduction
Webinar Outline
Webinar Requirements
Webinar Protocol
Webinar Objective
Sample CBR
CBR Purpose
Focus
Demographics
Webinar Materials
Acronyms
Coverage and Documentation Overview
Topic Selection
Other Investigations
False Claims Act
What is a Modifier
Modifier 25
Surgical Package
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
1
Minor Procedures
Major Procedure
Medicare Physician Fee Schedule Database (MPFSDB)
Determine the Global Period
Global Periods
Correct Use of Modifier 25
Incorrect Use of Modifier 25
Documentation
American Academy of Family Physicians (AAFP)
IPPE or AWV on Same Day as an E/M Service
Allowed Time for E/M Services
Use of Time to Determine the Level of E/M Service
References
Evaluation and Management Services
Surgeons and Global Surgery
NCCI Policy Manual
Office of Inspector General
Methods and Results
Report Data
Peer Groups
Data Source
Table 1
Understanding Table 1
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
2
Comparison Outcomes
Percentage of Claim Lines with Modifier 25
Table 2
Calculating Percentage of Claim Lines with Modifier 25
Average Allowed Minutes per Visit
Average Allowed Minutes per Visit with Modifier 25 and without Modifier 25
Table 3
Average Allowed Charges per Beneficiary
Table 4
Calculating Average Allowed Charges per Beneficiary
Resources
CBR Webinar
FAQs
Additional Resources
Next Steps
Provider Self‐audit
Contact Information
CBR Support Help Desk
Questions and Answers
Contacting MACs
NPPES
47
48
49
50
51
52
53
54
55
56
57
58
59
60
61
62
63
64
65
66
3
CBR201409
Modifier 25: Family Practice
4
The CBR project has made every reasonable effort to ensure
the accuracy of the information and web links provided in
the CBR materials at the time of publication; however,
Medicare policy changes frequently, so the information and
links within the material may change without further notice.
It is the responsibility of the provider to remain up-to-date
with Medicare Program requirements.
5
CBR materials are prepared as a service to the public and
are not intended to grant rights or impose obligations. The
information provided in the CBR material is only intended to
be a general summary. It does not supersede or alter the
coverage and documentation policies outlined in the local
coverage determinations (LCD) and policy articles for the
A/B Medicare Administrative Contractors (MAC) or DME
Medicare Administrative Contractors (DME MAC). Please
refer any specific questions you may have to the A/B or DME
MAC for your region. We encourage providers to review the
specific statutes, regulations, and other interpretive material
for a full and accurate statement of their contents.
6
Webinar Outline
1.
Introduction
2.
Coverage & Documentation Overview
3.
References
4.
Methods & Results
5.
Resources
6.
Next Steps
7.
Contact Information
8.
Q&A
9.
Survey
7
Webinar Requirements 
Landline for conference call
(cell phones are not recommended)

Wired (not wireless) broadband internet
connection

PC computer using Windows or Mac operating
system

Android or iPad tablets

Latest version of Adobe Flash installed
8
Webinar Protocol

All attendee lines are muted

Submit questions via chat when prompted
by speaker

Submit questions during the Q&A session
at the end of webinar

Ask questions pertinent to webinar

Contact MAC for specific claims questions
9
Webinar Objective
Upon completion of this webinar the participant
should be able to:
 Demonstrate a general understanding of the
CBR for modifier 25

Comprehend the report methods used to
develop the report

Locate policy references and resources for
modifier 25
10
Sample CBR
Provided for each topic
http://www.cbrinfo.net/
11
CBR Purpose
Designed to:
 Provide education to the provider community

Compare billing practices among Medicare
providers and their peer groups
The CBR does not:
 Imply any assumption of wrong-doing

Serve as a pre-cursor to an audit
12
Focus
This CBR examines:
 Percentage of claim lines with modifier 25
appended

Average allowed minutes per visit for claim lines
with modifier 25 and without modifier 25

Average allowed charges per beneficiary
13
Demographics

10,000 providers

Data from claims paid by traditional
Fee For Service (FFS) Medicare

Billing patterns different from their peers
14
Webinar Materials

References and Resources

Webinar slides

MP4 of webinar

Webinar Handout

Webinar Q&A Handout
Recommended Links:
http://www.cbrinfo.net/cbr201409-recommended-links.html
Resources from event:
http://www.cbrinfo.net/cbr201409-webinar.html
15
Acronyms
AAFP:
American Academy of Family Physicians
AWV:
Annual Wellness Visit
CBR:
Comparative Billing Report
CPT:
Current Procedural Terminology
E/M:
Evaluation and Management
IPPE:
Initial Preventive Physical Exam
NCCI:
National Correct Coding Initiative
OEI:
Office of Evaluation and Inspections
OIG:
Office of Inspector General
16
Coverage & Documentation Overview
17
Topic Selection
Office of Inspector General (OIG)
http://oig.hhs.gov

Use of Modifier 25, November 2005, OEI–07–03–
00470



Medicare requirements not met: 35% of services
Improper payments: Estimated at $538 million
In 2002, Medicare allowed $1.96 billion for approximately 29 million claims billed
http://oig.hhs.gov/oei/reports/oei-07-03-00470.pdf
18
Other Investigations New York State, Office of the State Comptroller

United HealthCare: Certain Claim Payments for
Evaluation and Management Services, April 2012,
Report 2010–S–67
Audited:
Results:
New York State Health Insurance Program
claims
12.6% did not meet requirements for
appending the 25 modifier
http://osc.state.ny.us/audits/allaudits/093012/10s67.pdf
19
False Claims Act
The United States Attorney’s Office, Northern
District of Georgia

Leading Oncology Practice to Pay $4.1 Million to
Settle False Claims Act Investigation, Press Release:
September 19, 2012

Settlement with Georgia Cancer Specialists I, PC


27 offices in Atlanta metro area
$4.1 million for violations of the False Claims Act
http://www.justice.gov/usao/gan/press/2012/09-19-12b.html
20
What is a Modifier?
CPT® modifiers:

Provide the means to report or indicate that a
service or procedure that has been performed has
been altered by some specific circumstance but not
changed in its definition or code

Append CPT® and HCPCS codes to add specificity

Two types: Level I (CPT®) and Level II (HCPCS)
21
Modifier 25
Used to support 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”
American Medical Association:
http://www.ama-assn.org/ama/pub/physician
resources/solutions-managing-your-practice/
coding-billing-insurance/cpt.page
22
Surgical Package
Always includes:

Local infiltration, metacarpal/metatarsal/digital block
or topical anesthesia

Subsequent to the decision for surgery, one related
E/M encounter on the date immediately prior to or
on the date of procedure (including history and
physical)

Immediate post-operative care, writing orders, post
anesthesia care and routine follow up
CPT® Assistant Articles:
http://www.findacode.com/cpt/cpt-assistant/index.html
23
Minor Procedures
Global period of 000 or 010 days: a minor
surgical procedure

In general, E/M services on the same date of service as
the minor surgical procedure are included in the payment
for the procedure

Example: removal of a foreign body from the hip
24
Major Procedure
Global period of 090 days: defined as a major
surgical procedure

Evaluation and management services performed on
the same day as the procedure are payable, when
reported with modifier 57, if the E/M was done in
order to determine the need for the surgery

Example: total hip replacement
25
Medicare Physician Fee Schedule Database (MPFSDB)
Instructions:

http://www.cms.gov/a
pps/physician-fee
schedule/help/Medicar
e-Physician-Fee
Schedule-Search
Help.pdf
26
Determine the Global Period
Medicare Physician Fee Schedule Database:
http://www.cms.gov/apps/physician-fee-schedule/overview.aspx
1.
Select “Physician Fee Schedule Search”
Screen defaults to current year
2.
Under “Type of Information,” select
“Payment Policy Indicators”
3.
Choose a single code/multiple codes/code range
Then enter the appropriate code(s)
4.
Select a modifier or “All Modifiers”
5.
Refer to the column heading “Global”
27
Global Periods
000:
Zero global days
010:
Ten global days
090:
Ninety global days
XXX:
Global concept does not apply
YYY:
Defined by A/B MAC
ZZZ:
Related to another procedure
MMM:
Maternity codes, usual global period does
not apply
28
Correct Use of Modifier 25
The patient was evaluated for treatment of neck
pain and insomnia:

Trigger point injections were administered to three
muscles for neck pain
CPT® code 20553: trigger point injections (000 global days)

The patient was also evaluated for new onset of
insomnia and meds were prescribed
CPT® code 99213–25: evaluation and treatment of insomnia
29
Incorrect Use of Modifier 25
The patient was seen for a second appointment for
a non-healing wound:

Physician debrided the skin and subcutaneous tissue
CPT® code 11042 only

No other conditions were addressed

Documentation reflected only the physician’s time,
examination and medical decision making to
determine the need for the debridement

Do not submit CPT® code 99213–25
30
Documentation
Auditors should be able to see the additional
work that was involved
Documentation must support:





History
Exam
Knowledge
Work time
Risk
Above and beyond what is usually required for
the surgery or procedure
31
American Academy of Family Physicians (AAFP)

The key components of a problem-oriented E/M
service for the complaint or problem must be
documented

The problem/complaint must stand alone in order to
be a billable service

A different diagnosis is not required

If same diagnosis, documentation must support
extra work above and beyond pre- or post-operative
work associated with the procedure
Understanding When to Use Modifier-25:
http://www.aafp.org/fpm/2004/1000/p21.html
32
IPPE or AWV on Same Day
as an E/M Service
IPPE (“Welcome to Medicare” visit) or AWV:

Modifier 25 is not appended

No part of the IPPE or AWV documentation can be
used toward the medically necessary E/M
Additional E/M service:

Modifier 25 is appended to the additional E/M service
33
Allowed Time for E/M Services
CPT® Code
Allowed Time
E/M Level
99211
5 minutes
Minimal problem
99212
10 minutes
Self-limited or minor
99213
15 minutes
Low to moderate severity
99214
25 minutes
Moderate to high severity
99215
40 minutes
Moderate to high severity
34
Use of Time to Determine the Level of E/M Service
“When counseling and/or coordination of care
dominate (more than 50%) of the time a physician
spends with a patient during an evaluation and
management (E/M) service then time may be
considered as the controlling factor to qualify the
E/M service for a particular level of care.”
Proper documentation must be in the patient’s
medical record
American Medical Association, CPT® 2013 Professional Edition
http://www.amazon.com/2013-Standard-Current-Procedural
Terminology/dp/1603596836/ref=sr_1_6?s=books&ie
=UTF8&qid=1412807444&sr=1-6
35
References
36
Evaluation & Management Services
Medicare Claims Processing Manual, Chapter 12—
Physician/Non-physician Practitioners
http://www.cms.gov/Regulations-and
Guidance/Guidance/Manuals/Downloads/clm104c12.pdf

Section 30.6.1—Selection of Level of Evaluation
and Management Service

Section 30.6.1.1—Initial Preventive Physical
Examination (IPPE) and Annual Wellness Visit (AWV)

Section 30.6.6—Payment for Evaluation and
Management Services Provided During
Global Period of Surgery
37
Surgeons and Global Surgery
Medicare Claims Processing Manual, Chapter 12—
Physician/Non-physician Practitioners
http://www.cms.gov/Regulations-and
Guidance/Guidance/Manuals/Downloads/clm104c12.pdf

Section 40.1—Definition of a Global Surgical Package

Section 40.2—Billing Requirements for Global
Surgeries
38
NCCI Policy Manual
National Correct Coding Initiative (NCCI) Policy
Manual for Medicare Services, Revision Date:
January 01, 2014
http://www.cms.gov/Medicare/Coding/NationalCorrectCodInitEd/Downloads/NCCI_
Policy_Manual.zip

Chapter I—General Correct Coding Policies

Section D—Evaluation and Management (E&M) Services

Section E—Modifiers and Modifier Indicators
39
Office of Inspector General

Use of Modifier 25, November 2005, OEI–07–
03–00470
http://oig.hhs.gov/oei/reports/oei-07-03-00470.pdf

Improper Payments for Evaluation and
Management Services Cost Medicare Billions in
2010, May 2014, OEI–04–10–00181
http://oig.hhs.gov/oei/reports/oei-04-10-00181.pdf
40
Methods and Results
41
Report Data
Medicare Part B Rendering Provider
 By National Provider Identifier (NPI)

Specialty 08 (Family Practice)

CPT® codes 99211–99215
Peer groups

Used for comparison with the individual providers
42
Peer Groups
State

Medicare providers in the provider’s state

E/M codes

Specialty of 08
National

All Medicare providers in the Nation

E/M codes

Specialty of 08
43
Data Source

CMS Integrated Data Repository 
Extracted: October 14, 2014

Dates of Service:
July 1, 2013 – June 30,2014
44
Table 1
Summary of Your Utilization for E/M Codes
and Modifier 25
July 1, 2013 – June 30, 2014
45
Understanding Table 1
Summary of Your Utilization for E/M Codes
and Modifier 25
July 1, 2013 – June 30, 3014
46
Comparison Outcomes
Three possible outcomes
1.
Significantly Higher
2.
Higher
3.
Does Not Exceed
47
Percentage of Claim Lines with Modifier 25
Calculated as follows:
48
Table 2
Percentage of Claim Lines with Modifier 25
July 1, 2013 – June 30, 2014
49
Calculating Percentage of Claim Lines with Modifier 25
Table 1: Summary of Your Utilization for E/M Codes and Modifier 25
July 1, 2013 –June 30, 2014
0 ൅ 6 ൅ 90 ൅ 863 ൅ 105
‫ݔ‬100 ൎ 85
1247
50
Average Allowed Minutes per Visit
Calculate total weighted value for each visit and
modifier designation:
1.
Separate claim lines by modifier designation

With modifier 25

Without modifier 25
2.
Assign value to each CPT® code by typical
minutes
3.
Multiply assigned value by number of services
4.
Visits with multiple claims are combined
51
Average Allowed Minutes per Visit
with Modifier 25 and without Modifier 25
Calculated as follows:
52
Table 3
Average Allowed Minutes per Visit
with Modifier 25 and without Modifier 25
July 1, 2013 – June 30, 2014
53
Average Allowed Charges
per Beneficiary
Calculated as follows:
54
Table 4
Average Allowed Charges per Beneficiary
July 1, 2013 – June 30, 2014
55
Calculating Average Allowed Charges per Beneficiary
Table 1: Summary of Your Utilization for E/M Codes and Modifier 25
July 1, 2013 –June 30, 2014
121,492.42
ൎ 113.12
1,074
56
Resources
57
CBR Website

About Us

CBR Releases

CBR Support

Education

Recommended Links

FAQs

Contact Us
http://www.cbrinfo.net/
58
FAQs
General FAQs
CBR Specific FAQs

CBR201409 Modifier 25: Family Practice
http://www.cbrinfo.net/cbr201409-faqs.html
59
Additional Resources

Medicare Learning Network®. Global Surgery
Fact Sheet, August 2013. ICN 907166
http://www.cms.gov/Outreach-and-Education/Medicare-Learning
Network-MLN/MLNProducts/downloads/GloballSurgery-ICN907166.pdf

Felger, Thomas A., MD and Marie Felger.
Understanding When to Use Modifier-25.
Family Practice Management, October 2004.
http://www.aafp.org/fpm/2004/1000/p21.html

Lansey, Debra. Learn Proper Coding for Modifier 59 and 25. ACP Internist, July/August 2012.
http://www.acpinternist.org/archives/2012/07/coding.htm
60
Next Steps
61
Provider Self-audit

Providers and suppliers have an obligation to
ensure claims are submitted to Medicare
correctly

Self-audits allow providers and suppliers to
identify coverage and coding errors

Refer to the following CBR sections for
assistance

Documentation and Billing

References
62
Contact Information
63
CBR Support Help Desk
Monday–Friday: 9:00 a.m. to 5:00 p.m. ET

Toll Free 1–800–771–4430

Email: [email protected]
64
Contacting MACs
Providers should contact the Medicare
Administrative Contractor (MAC) for assistance
with:
 Claim Information
 Documentation Requirements
 Billing and Coding
Locate Your MAC:
http://www.cms.gov/Research-Statistics-Data-and
Systems/Monitoring-Programs/Medicare-FFS-Compliance
Programs/Review-Contractor-Directory-Interactive-Map/
65
NPPES
National Plan and Provider Enumeration System

Source for mailing address used for the CBR

Correct your mailing information at https://nppes.cms.hhs.gov/NPPES
66
Questions & Answers
67

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