What’s the story with my exam denials?

The automatic appending of Modifier -25 on Evaluation & Management (E&M) services has been a concern of insurance payers for quite some time. In years past, we were able to simply append a -25 modifier to communicate that additional service beyond the usual pre-and post-service work associated with the primary service.
In recent reports, the Office of the Inspector General (OIG) and the Center of Medicare and Medicaid Services (CMS) identified the use of modifier 25 as an area of potential misuse and abuse. In an effort to reduce and prevent fraud, waste, and abuse among private payers, we have seen rolling implementation of claims & coding intelligence software we are seeing this modifier denying automatically and higher scrutiny similar to that of -59 modifiers. 

Among specialties, like chiropractic, which the OIG (the 17th & most recent full report https://oig.hhs.gov/oas/reports/region9/91602042.pdf on the specialty) has specifically singled out there has been an increase in the interest of doing the same among other private insurers.

When used & documented appropriately the exam with a -25 modifier may be reimbursable by your local payer. To add, it is extremely important that you are using diagnosis pointing properly especially in cases where you are evaluating new presenting issues.
Using the example of chiropractic services, according to the AMA’s CPT manual you may bill an E&M service with a -25 modifier in the following cases:

  • A new patient visit (pre-spinal manipulation) in which you also adjust on the first visit
  • An established patient presenting with new condition, new injury, aggravation, or exacerbation, and the decision is made to also perform spinal manipulation on that visit
  • A periodic re-evaluation to assess if a treatment change is needed, and the decision is made to provide treatment the same day (It is important to know your insurer’s definition of “periodic” to understand the frequency in which this can be done)

Keep in mind, just because a service is billable doesn’t mean your payers will allow the service to be billed. Payers are allowed to set their own rules and according to your provider contract, they can modify these rules periodically. In recent months we have seen payers implement such policy changes. When new contract rules are set by payers, we may not be able to appeal related denials. For example in Anthem BCBS of Virginia‘s recent update: 
Beginning with claims processed on or after March 1, 2019, Anthem may deny the E/M service with a modifier -25 billed on the day of a related procedure when there is a recent service or procedure for the same or similar diagnosis on record.
Source: https://providernews.anthem.com/virginia/article/update-regarding-evaluation-and-management-with-modifier-25-same-day-as-procedure-when-a-prior-em-for-the-same-or-similar-service-has-occurred-professional
They go on to say: 
If you believe a claim should be reprocessed because there are medical records for related visits that demonstrate an unrelated, significant, and separately identifiable E/M service, please submit those medical records for consideration.

Aetna has implemented a similar protocol with its recent addition of new coding tools.
With these examples, we are able to appeal the denials to support the use of the -25 modifier, however, it is important for you, the provider, to know whether you have used the codes & modifiers properly and documented effectively.
We here at IPS are not certified chart auditors or coding experts, however, we have resources we would love to connect you with if you are unsure whether you are coding or documenting properly.  If you’re interested in learning more about these resources, please reach out to us.

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