UCR 101: Modifier 25 - deep dive
June 24, 2022
Mark and Scott welcome Dr. John Lin to the podcast to discuss in detail Modifier -25.
Skyline Urology to Pay 1.85M to Settle False Claims Act Allegations of Medicare Overbilling
Also Corporate Integrity Agreement
OIG Audit Modifier 25
https://oig.hhs.gov/oei/reports/oei-07-03-00470.pdf
NCCI Policy Manual: https://www.cms.gov/medicare/national-correct-coding-initiative-edits/ncci-policy-manual-medicare
Chapter 7: GU System
The decision to perform a minor surgical procedure is included in the payment for the minor surgical procedure and shall not be reported separately as an E&M service. However, a significant and separately identifiable E&M service unrelated to the decision to perform the minor surgical procedure is separately reportable with modifier 25.
Cigna:
https://www.cmadocs.org/newsroom/news/view/ArticleId/49780/Cigna-to-require-medical-records-for-all-modifier-25-claims
Cigna’s Modifier Policies: https://static.cigna.com/assets/chcp/resourceLibrary/clinicalReimbursementPayment/medicalClinicalModifiersPolicies.html
Cigna’s Modifier 25 Policies:
https://static.cigna.com/assets/chcp/secure/pdf/resourceLibrary/clinReimPolsModifiers/Notifications/Modifier_25_Significant_Separately_Identifiable_Evaluation_and_Management.pdf
Horizon BCBS: Beginning on August 1, 2022, we will consider E&M services appended with Modifier 25 at 50 percent of our appropriate Horizon allowance (or at the provider’s submitted charges if less) if one or more procedure codes that have a global surgical period of 0, 10 or 90 days are included on the same claim or on another claim for that same date of service.
BCBS of Massachusetts: Effective July 18, 2022, we will enhance our claims editing system to improve its overall accuracy regarding modifier usage. Currently, some modifiers including, but not limited to, 25, 59 (X-EPSU subset), 79, and 24 are inappropriately overriding unbundling edits in certain situations. Based on an extensive assessment of modifier use, the Office of Inspector General (OIG) and the Centers for Medicare & Medicaid Services (CMS) have advised the use of pre-payment modifier review based on claim details and patient claim history.
Consistent with the recommendations of the OIG and CMS, Blue Cross will implement enhanced editing based on national guidelines for modifier usage. As part of this process, registered nurses with coding certifications will look at claim data in conjunction with patient claim history to confirm appropriate modifier use.
Dr. Lin is the administrator of The Thriving Urology Practice Facebook group.
The Thriving Urology Practice Facebook Group link to join:
https://www.facebook.com/groups/ThrivingPractice/
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"Beef Up" On your Urology Coding Knowledge
PRS Network Presentation Team
- Dr. John Lin
- Mark Painter
- Scott Painter
From the perspective of a practicing Urologist and experts In Urology Coding.
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