Recent payer policies will only reimburse 50% when an E/M and procedure are performed on the same day.
Payers are now adding a layer of complexity by reducing the Evaluation and Management (E/M) service payment by 50% when a separately identifiable E/M service is provided in addition to the minor procedure performed. The use of Modifier 25 with an E/M service to identify this scenario has long been a source of confusion, and it has been closely scrutinized for potential overuse and abuse by the Office of Inspector General (OIG).
What is Modifier 25?
Modifier 25 is defined as 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” (CPT 2024).
How to Use Modifier 25?
To appropriately report Modifier 25, there must be a significant, separately identifiable, E/M service supported by documentation that meets the relevant criteria for the respective E/M service. It’s important to note that the global surgical package for every procedure includes a certain level of evaluation and assessment to carry out the procedure.
CMS considers an E/M service performed on the same day to be inherent to the procedure and will only reimburse for an E/M service if the work involved goes above and beyond the preoperative/postoperative evaluation services. (Source: NCCI Chapter 12 pg. 33.)
Please see our previous blog on Using Modifier 25 Correctly from November 2021, here Modifier 25.
Global Surgical Package
Keep in mind that the Global Surgical package varies depending on the specific procedure, encompassing a range of essential services such as E/M, certain anesthesia services, order writing, and postoperative care. Therefore, different diagnoses are not necessary to report the E/M services on the same date. However, the documentation must support medical necessity and reflect medical decision-making going “above and beyond” the normal services included on the same day of the procedure. When documentation meets this requirement, the separately identifiable problem addressed can be specified by adding modifier 25 to the appropriate level of E/M.
The following services are considered included in the global surgery payment when provided in addition to the surgery.
- Pre-operative visits, after the decision is made to operate. For major procedures, this includes preoperative visits the day before the surgery.
- For minor procedures, this includes pre-operative visits the day of surgery.
- Intra-operative services that are normally a usual and necessary part of a surgical procedure.
- All additional medical or surgical services required of the surgeon during the post-operative period of the surgery because of complications, which do not require additional trips to the operating room.
- Follow-up visits during the post-operative period of the surgery that are related to recovery from the surgery.
- Post-surgical pain management by the surgeon.
- Supplies, except for those identified as exclusions.
- Miscellaneous services, such as dressing changes, local incision care, removal of operative pack, removal of cutaneous sutures and staples, lines, wires, tubes, drains, casts, and splints; insertion, irrigation and removal of urinary catheters, routine peripheral intravenous lines, nasogastric and rectal tubes; and changes and removal of tracheostomy tubes.
When Are Changes Happening?
Effective April 19, 2024 for BCBS of Texas, July 14, 2024 for BCBS of California, and September 1, 2024 for BCBS of **North Carolina, these payers will reduce reimbursement of certain office and other outpatient visit E/M by 50% when appended with modifier 25 and billed with a minor surgical procedure code (0- or 10-day global period). According to Blue Shield, the rationale for the decision is to “no longer reimburse for the practice expense component twice, once for the E/M service, and again for the global day code.”
For some payors such as Horizon BCBS, the 50% reduction in reimbursement policy change took effect on February 1, 2023. As of June 25, 2024, several Blues are following suit:
BCBS of Texas April 19, 2024
*BCBS of California July 14, 2024
**BCBS of North Carolina September 1, 2024 – Decision rescinded by BCBS 6/27/2024
What You Should Do Now
Providers should ask themselves the following questions to determine if modifier 25 is appropriate:
- Did you perform and document the key components of a problem-oriented E/M service for the complaint or problem?
- Could the complaint or problem stand alone as a billable service?
- Did you perform extra work that went above and beyond the typical pre or postoperative work associated with the procedure code?
It’s important to note that other payors are likely to follow suit to reduce their reimbursement policies for E/M services when Modifier 25 is used. Immediate and focused attention is needed to understand and adapt to these changes and to stay informed about potential future changes.
*Physicians with concerns or questions about the policy can contact Blue Shield Provider Services via live chat after logging in at blueshieldca.com/provider or by phone at (800) 541-6652. Physicians may also wish to contact their specialty societies to urge them to engage with Blue Shield on this policy change.
