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In urgent care today, an episodic visit can quickly morph into a conversation about other symptoms not related to the original reason for a visit. Do you know how to use E/M modifier 25 appropriately when it’s the right call?

In this month’s “3 Things to Know About RCM,” we’ll provide answers to your E/M modifier 25 questions and share updates to help you recover accurate reimbursement for COVID-19 infusions and vaccine administration.

Modifier 25: 5 Questions to Ask Yourself Before Applying E/M-25

Using Modifier 25 can be tricky. Use these five questions to determine whether modifier 25 applies to a specific encounter. Billing a separate E/M while using this modifier (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) correctly will help you collect the most accurate reimbursement for services – and avoid payer scrutiny.

  1. What is the purpose of the encounter?
    The first line of documentation indicates what brought the patient into the office. That is the purpose of the encounter. Unless the clinician did something else significant and separate from the initial purpose on the same day of the encounter, you cannot use a separate E/M with modifier 25.
  2. Were there additional workups during the visit unrelated to the procedure?
    If the provider’s documentation goes beyond describing the initial procedure, there may be an opportunity for documenting a significant and separate E/M. Check the record for additional workups like unrelated labs or diagnostic tests, x-rays, studies, or even referrals to a specialist. These workups provide support for using a separate E/M and modifier 25.
  3. Did the provider began a new treatment plan?
    If the provider’s documentation indicates the encounter included discussions about an unrelated condition or separate existing problem, it supports a separate E/M and applying modifier 25.
  4. Did the provider do additional work above and beyond the initial procedure?
    Before billing for a separate E/M with modifier 25 it’s imperative to determine whether a provider performed any additional work above and beyond the work involved in the procedure. This means knowing what typical pre- and post-work is included in the procedure code and how that is different from separate and unrelated work. Typical pre- and post-work does not qualify under modifier 25. But if something in the encounter notes indicates a provider spent additional time on the procedure, or that there is something unique or unusual about it, dig deeper into the documentation or query the provider to see if there is a case for a separate E/M. Be sure you’re clear before you make a determination.
  5. Was there a new diagnosis?
    A new diagnosis, separate from any diagnosis related to the procedure, would also create a strong case for E/M-25.  Keep in mind, a new diagnosis is not required to justify a significant and separate E/M service. Be sure a new diagnosis is on the claim form and, if performed, include an assessment.

According to Mary I. Falbo, MBA, CPC, CEO of Millennium Healthcare Consulting Inc., an E/M service with modifier 25 will be seen as medically necessary if you can prove:

  • The provider did not schedule the procedure or service
  • The provider uncovered signs or symptoms that needed to be addressed
  • The provider addressed more than one diagnosis
  • The provider performed work above and beyond normal work for a given procedure

Always be sure you can support using a separate E/M code with modifier 25 when billing. It will not only result in cleaner claims and quicker resolution but will keep claims from undue scrutiny.

Source: Primary Care Coding Alert – 2021; Volume 23, Number 6

New Reimbursement Rates on COVID19 Infusions

According to the Centers for Medicare & Medicaid Services (CMS), beginning May 6, providers can expect a bigger reimbursement for administering monoclonal antibody infusions to Medicare beneficiaries with COVID-19.

Nationally, the average payment will go up from $310 to $450 in most healthcare locales, according to the release. The agency also plans to “establish a higher national payment rate of $750 when monoclonal antibodies are administered in the beneficiary’s home.”

The decision to boost payment rates was in part the result of a review of new information on the costs of administering COVID-19 treatments to sick patients.

Additional Reimbursement for COVID-19 Vaccine Administrations

Effective 06/08/2021, Medicare will pay an additional $35.00 per vaccine administration when performed in the patient’s home. This increases the payment amount per vaccine to $75.00 per dose.

  • To qualify for the travel allowance, vaccine administration has to be the sole purpose of the visit. You get one $35.00 payment regardless of the number of patients vaccinated in the home.
  • Documentation should include their clinical status or the barriers they face to getting the vaccine outside their home. To report, use POS 12 (Home) and HCPCS code M0201.
  • This should include Medicare Advantage patients as these claims go to original Medicare. It’s not known if private payers will offer the same benefit.

See the details.

Interested in more urgent care tips, best practices, and industry updates? Check out our May and June installments.

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