Untangling Modifier 25: What You Need to Know

In this debut episode, Mary Pat Johnson and Rebecca Greenlaw of Corcoran Consulting Group break down the complexities of Modifier 25. From Medicare’s shifting guidance to documentation pitfalls, they discuss when it applies, common mistakes, and best practices to protect compliance. Learn how to distinguish exceptions, strengthen charting, and stay ahead of evolving rules.

Contact us by calling (800) 399-6565 or visiting CorcoranCCG.com

Transcript

Welcome to Ophthalmology Reimbursed, the podcast that discusses all things coding, reimbursement, auditing, and education for the ophthalmic community. Hi everyone, I'm Mary Pat Johnson with Corcoran Consulting Group here with my colleague Rebecca Greenlaw. Hi guys.

Thanks for joining us. We are going to present the web that is Modifier25 in today's inaugural issue of our new podcast, so we appreciate you being here with us and helping us kick this off. Rebecca, my phone's going crazy.

How about you? Mine too. I've noticed the increased concern over the scrutiny surrounding Modifier25, so let's dive in. Yeah, and I don't think Medicare has made it any easier. 

They published a rule in the spring, they took it down, and they put it back up with some slight modifications, which has people a bit concerned. So where do you think we begin? There's a few points I want to make. Well, let's start with what's included in the exam when you're doing a minor procedure.

That's a great place. Let's talk about when this modifier is used. When your charts support a separately billable exam on the day of a minor surgery, you need to report this Modifier25.

Now, that's not every visit, and I know some physicians want it to be, but the rules for minor surgery say the exam performed on the day of the minor surgery is not separately payable. Are there exceptions? Of course, and that's where this modifier comes in. The problem is folks are having a hard time distinguishing what is separately identifiable, and they're having a hard time with the word exception. 

We're finding it's being done on more encounters than not. Exception, by its definition, means it should be fairly rare. So the issue is, when do you get to bill it? What does CMS have to say in their most recent edict on that, Rebecca? Well, I think this is why this continues to be an issue with the Modifier25, and it's interesting that we find that this topic was reopened on the OIG website just this last month in September.

Right about the time that New Med Learns Matters came out, then. Right, and it has some new language in it that is confusing, and it's contradicting the reference source that it gives, which is the NCCI policy manual. Mm-hmm.

Well, I saw the new language that focuses most of their discussion on injections, so while it applies to all minor surgery, this particular document talks mostly about intervitreal injections. And the contradiction, I think, that you're referencing comes with the description of a new condition or a new treatment, correct? Right, right. Yeah, I'm not sure that's going to stand up.

There's been a lot. I've even had a couple consultants call wanting to debate that one. I think physicians are going to respond, and I'll be curious to see how Medicare follows up with that.

Right, and did you notice that it also talks about regardless of whether the patient is new or established? Right, yeah, and that's been in the instruction for a while. I know commercial insurances oftentimes will let you bill that new patient encounter, but new patient visits, according to Medicare, they treat the same way as established. Right.

Yeah, so some of the pushback I've been getting when the phone rings is, first off, bilateral injections. Why can't I bill an exam with a bilateral injection? What's your advice there? Well, I think we need to look at, is there anything new or separately identifiable that's happening when a bilateral injection is happening? Are we evaluating glaucoma? Are we evaluating, you know, a complaint of eyelashes getting in the eyes? Right, right. I think a doctor explained it to me the other day when he finally, the light bulb finally went on.

He said, so what you're telling me is I need a new diagnosis or a third eye to support the office visit. And I thought, well, you're probably more likely to get the diagnosis. Right.

So yeah, the bilateral injection patients, I think we're going to rarely support an office visit. So let's go back to the idea of a chronic condition, though. If Medicare is going to argue that this has to be a new condition, that steps kind of all over the previous policy that says Medicare covers visits to re-evaluate stable chronic conditions.

So because these patients have bilateral disease, when only one eye is treated, I think that that still opens the door for a separately billable visit. But do you think a new complaint with the chronic condition applies? So the patient comes in and they have wet AMD in one eye, dry AMD in the other eye, but oh, I'm noticing a decreased, a decrease in my vision with the eye with the dry. I think it'd be helpful.

A new complaint in the non-injected eye? No. Yeah. What I think we need to remind physicians of is just because the patient's in to treat one eye doesn't mean you necessarily have to look at the fellow eye.

Right. And I'm not going to try and practice medicine for them. They know better than I. But I will remind them that their preferred practice pattern summary benchmarks talks about AMD in both category 2 and category 4, and they think looking at those patients should be every 6 to 24 months, not once a month when you're treating the other eye.

So they do need to follow the instructions that their own specialty society provides. Right. Do you think this is enough to make physicians not bill the exam? I think some are going to go that route.

I would not encourage it. I think they should still bill for it when they can support it. In general, it happens on about 16% of office visits billed to Medicare.

So for retina, that number is probably twice that or three times that. So I think it's all dependent on what the patient has going on and what they put in the chart. Bottom line is they have to document it.

Exactly. So in talking about exam codes, we shouldn't discount the comprehensive eye code either. Yeah, I think the eye code will work there in some cases, depending on when you saw the patient last, what you did in today's visit, what you needed to do.

Certainly you don't need a comprehensive visit. Again, monthly. Spread those out to once or twice a year, whatever the policy for that particular payer would allow.

But I don't think eye codes are off the table. I agree. Mary Pat, what do you think a few of the to-dos that our listeners who are listening today can be doing right now? I think first we need to do a couple of things.

If they haven't looked at the MedLearn Matters update, they should probably get that. You can grab that off the CMS website. In the body of that, you can link to their reference material, which is the NCCI policy.

And then internally, if they're using this modifier a lot, they should probably audit a few charts. Make sure that they think their charts support it. We can help you with that if need be.

And then going forward, just increase your documentation. If you do intend to bill an office visit, make sure it clearly has two reasons for the encounter, aside from the injection, a treatment plan for the non-treated eye, everything you would expect for a billable visit. I agree.

Solid documentation is going to be key. Yeah. And we seem to say that a lot about most things they bill for.

Yeah, we do. Injections, visits. Yeah, documentation is everything.

Thanks for your time. Thanks. One final comment before we sign off.

For those of you who are attending the Academy of Ophthalmology meeting the weekend of October 17th, look for us there. We'll be in Orlando doing presentations for both the Administrators Program and the Nursing Technicians Program. We'll be participating in the OOS meeting and spend a lot of time on the Exhibit Hall floor.

So look us up, shoot us a message ahead of time if you want to schedule a minute to get together and address questions. Thanks for listening to Ophthalmology Reimbursed, brought to you by Corcoran Consulting Group, the experts in coding, reimbursement, auditing, and education for the ophthalmic community. To learn more about how we can support your practice, visit CorcoranCCG.com. Be sure to follow and leave a review wherever you listen to podcasts.

Until next time, thanks for listening to Ophthalmology Reimbursed.