Description
This policy addresses guidelines for services considered adjunctive to a basic service and systems logic that enforces code combinations when Modifiers 25, 27, 59, FT, XE, XP, XS or XU are present on the claim based on the Centers for Medicare & Medicaid Services (CMS) National Correct Coding Initiative (NCCI) and/or Blue Cross Blue Shield of North Dakota (BCBSND) direction.
Policy
Modifier 25
Modifier 25 is not to be used in situations when services provided are a part of the usual pre/post care related to the procedures(s). Modifier 25 represents the Evaluation and Management (E/M) service was performed for reasons unrelated to other procedure(s) performed on the same day. Providers may bill for both an Office/Outpatient E/M service and a Preventive E/M service when the below are met:
- New or preexisting problem is addressed during a Preventive E/M service and
- New or preexisting problem is significant enough to require additional work to perform the key components of a problem-oriented E/M
If all above criteria is met, both the Preventive E/M and the Office/Outpatient E/M codes may be billed for reimbursement. Providers should append modifier 25 to the Office/outpatient E/M code based on the American Medical Association (AMA) E/M Preventive Medicine Services Coding Guidelines.
Providers should not bill a Preventive E/M and an Office/Outpatient E/M service when:
- New problem is addressed during a Preventive E/M service requiring no additional work
- Preexisting problem acknowledged in the record however no additional work was done for the problem
Modifier 27
Modifier 27 is for hospital/outpatient facilities to use when multiple outpatient hospital E/M encounters occur for the same member on the same date of service. Modifier 27 is exclusive to hospital outpatient departments, including hospital emergency departments, clinics, and critical care.
Modifier FT
Effective January 1, 2022, modifier FT may be used to report an unrelated E/M visit during a postoperative period, or on the same day as a procedure or another E/M visit. Providers may report modifier FT when an E/M visit is furnished within the global period but is unrelated, or when one or more additional E/M visits furnished on the same day are unrelated. For instance, this modifier may be used for critical care performed by a surgeon during a global period; however, the critical care must be unrelated to the procedure/surgery done.
Physician Assistants providing unrelated care to a member during a global period must report modifier FT on the unrelated service(s). Unrelated E/M’s performed by the surgeon, or by another physician or other QHP within the same group and/or same specialty and sub-specialty, during the global period may use the 24 or FT modifier to indicate the service was unrelated. If the FT modifier is not appended the service will be rejected as related to the global surgery.
Modifiers 59, XE, XP, XS & XU
CMS NCCI edits indicate when the presence of an override modifier is permitted to bypass code combination logic, and to allow separate reimbursement for both the combination code and the component code. When NCCI indicates code combinations that are never allowed separate reimbursement for both procedures, our reimbursement will be limited to the allowance of the higher paying procedure of the code combination. This involves claims for the same patient, same date of service and the same provider specialty and sub-specialty.
Enhanced Ambulatory Patient Groups (EAPGs)
Outpatient facility claims billed on the UB-04 Claim Form must use modifiers 25 or 59 to bypass payment consolidation for separate visits or procedures. Modifiers XE, XP, XS & XU will not bypass consolidation for separate procedures processed under Enhanced Ambulatory Patient Groups (EAPGs).
Limitations & Exclusions
While reimbursement is considered, payment determination is subject to, but not limited to:
- Group or Individual benefit
- Provider Participation Agreement
- Routine claim editing logic, including but not limited to incidental or mutually exclusive logic, payment integrity edits and medical necessity.
- Mandated or legislative required criteria will always supersede.
In instances where the provider is participating, based on member benefits, co-payment, coinsurance, and/or deductible shall apply.
Cross References
History
12/22/2020
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Added reference for how to use modifiers for facility outpatient claims processing with EAPG pricing.
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09/20/2021
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Updated format and added cross references
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12/14/2021
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Added 27 and FT modifier information
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2/16/2022
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Updated policy to align with the Preventive Medicine CPT guidelines allowing a Preventive E/M to be billed on the same date as an Office/Outpatient E/M if below are met:
- New or preexisting problem is addressed during a Preventive E/M service and
- New or preexisting problem is significant enough to require additional work to perform the key components of a problem-oriented E/M
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8/11/2022
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Policy has been reviewed. Removed information stating X modifiers are not allowed to override code combinations and corrected hyperlink for cross referenced National Correct Coding Initiative Edits | CMS. Changed occurences of "specialty" to "specialty and sub-specialty." |
8/3/2023
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Annual Policy review; added payment integrity edits to the 3rd bullet of the limitations and exclusions portion. |
