Modifier 25 + Intravitreal Injections + NCCI Bundles
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INFORMATION PROVIDED BY RIVA LEE ASBELL
Effective July 1, 2013, NCCI (National Correct Coding Initiative) edits were implemented bundling E/M (Evaluation and Management) and Eye Codes (except new patient services) with minor and major surgical procedures. The code pair edits (bundles) were added after CMS and NCCI deliberated because some MACs (Medicare Administrative Contractors) had erroneously processed claims in which both office visits and major and minor surgical procedures were paid although the appropriate modifier (either 25 or 57) had not been applied. This article focus es on using correct coding for office visits and intravitreal injections.
BACK TO BASICS-THE GLOBAL FEE
Medicare’s global fee concept definitively includes payment for the office visit in the total reimbursement for minor surgical procedures (a procedure with a 0- or 10-day global period). Medicare’s global fee for minor procedures is divided into three portions:
• 10% allotted for preoperative care;
• 80% for intraoperative care; and
• 10% for postoperative care.
Section 40.1B of CMS Internet Only Manual, Publication 100-04, Chapter 12 states, “The initial evaluation is always included in the allowance for a minor surgical procedure.” Specious arguments and rationalizations will not change this.
LEGITIMATE USE OF MODIFIER 25
Modifiers 24, 25, and 57 are NCCI-associated modifiers that allow consideration of payment for significant and separately identifiable E/M services, including 92012-92014. Modifiers 24 and 57 were added to the list of NCCI-associated modifiers as of January 1 to control MAC errors in claim processing. CMS ordered this reprogramming so that modifiers 25 and 57 can serve the function of breaking the NCCI bundles (code pair edits), thus engendering payment for the office visit and procedure. Implementation has been a rocky road.
Each bundle in the NCCI has a modifier-indicator that determines if the bundle can be broken. The pairing of CPT code 67028 + designated office visit has modifier-indicator “1” indicating it can be broken. This does not necessarily mean that it should be. The use of modifier 25 itself needs to be strictly controlled in its usage.
WHAT SHOULD YOU DO?
In my auditing experience, approximately only 5% of encounters for established patient office visits performed with intravitreal injections on the same day qualify as significantly separate and warrant separate billing. You should only bill established office visits with intravitreal injections when you are truly examining the patient for something other than the condition for which you are performing the intravitreal injection. An example of an allowable office visit is a patient presenting with symptoms of retinal detachment in the fellow eye.
Physicians and their billing departments should share this information. It is quite apparent from the many inquiries on the denials since July 1, 2013, that most practices have not had instruction on this. The Office of the Inspector General (OIG) has been highly interested in this for several years, and audits with serious consequences have occurred.
Based on an audit of charts for 100 intravitreal injections billed with office visits, only 15 were allowed and the recoupment was $211, 196 for calendar years 2008 through 2010.
This report stated, “The Hospital and the physicians were not eligible for the additional E&M payments since the services that the physician performed were not significant, separately identifiable, and above and beyond the usual preoperative work of the eye injection procedure.”
CPT codes copyrighted 2013 by the American Medical Association. RP