Modifier 25 is a critical part of the Medicare program, but it can be difficult to understand and use correctly. In this post, I’ll explain what Modifier 25 does, why it’s needed, and how to use it properly.

If a patient comes in for a preventive visit and the physician also performs a minor procedure, you do not need to use modifier 25 at all.

If a patient comes in for a preventive visit and the physician also performs a minor procedure, you do not need to use modifier 25 at all. In this case, Medicare will pay for the E/M service and the separately payable procedure (for example, ordering a test) as long as both are performed on the same day.

Modifier 25 is also used when there are two or more E/M services provided during the same day by different physicians who see patients at different times during their office hours. This includes doctors who provide care on an urgent basis in an emergency department or urgent care facility that is not part of their practice site where they normally see patients (see section II).

You’ll need to report modifier 25 for two or more E/M visits on the same day – even if one of them is a prolonged services code – if the visits are provided by different physicians.

You’ll need to report modifier 25 for two or more E/M visits on the same day – even if one of them is a prolonged services code – if the visits are provided by different physicians. This can occur when you have an established relationship with multiple specialists and you schedule several appointments in a single day, or if your frequent medical complaints require additional treatment from different physicians.

For example:

●    Dr. Jones schedules two 10-minute E/M visits for John Smith on Tuesday afternoon at 3 p.m., so she can see him before her vacation leave begins that night at midnight. She provides service during both of these encounters regardless of being paid separately for each visit. As such, she reports modifier 25 on both claims because they were provided by different physicians in the same patient visit date range (as indicated by Medicare’s billable period dates).

Make sure you’re using the correct E/M code for your documentation.

Make sure you’re using the correct E/M code for your documentation. If you’re not sure what code to use, ask your billing company. If the code is correct, but the modifier isn’t, you’ll need to resubmit the claim.

If you’re submitting an electronic claim for a patient who has Medicare Part B and gets back a rejection, check the Remark Code box to see what’s wrong.

If you’re submitting an electronic claim for a patient who has Medicare Part B and gets back a rejection, check the Remark Code box in the error message to see what’s wrong. If you don’t check the Remark Code box, you won’t know what’s wrong. Resubmission will most likely be required if you don’t check this box.

Another common reason for denial is that you didn’t attach an operative report to the claim.

The second most common reason for denial is that you didn’t attach an operative report to the claim. If you don’t attach an operative report, any claim for minor procedures will be denied. The operative report is required by Medicare as part of a valid request for payment. In contrast, major procedures do not require an operative report since there are no CPT codes that require this documentation.

If you don’t attach the appropriate documentation at all, the provider must request it from his or her patient before billing Medicare again and getting paid for that service. If something goes wrong with your medical procedure (i.e., if there’s some kind of complication), then this process can take several weeks longer than it would have otherwise because providers have to wait on patients to send in their records before submitting claims again—and every time something goes wrong with a procedure, physicians are losing money due to administrative delays caused by lack of proper documentation over what went right versus wrong during treatment sessions!

Modifier 59 is typically not acceptable instead of modifier 25.

In this case, you cannot claim two or more separate E/M services on the same day with modifier 59. If you did so and Medicare audited your claims, they would deny them because modifier 59 is only applicable to single E/M services provided on the same day as an outpatient procedure.

Modifier 25 is typically not acceptable instead of modifier 59. Modifier 25 is used to denote that a service was performed by multiple physicians (i.e., two or more physicians), whereas modifier 59 only allows for one physician performing an outpatient procedure or CPT code 99XXX-XX9X9X99ZX9X99ZX99ZX99ZWZZZZZZZZWZ in a given day.

Denials can be avoided when the rules are followed correctly.

You’ll avoid denials and get paid faster when you’re using modifier 25 correctly.

Modifier 25 is a code that serves to indicate that a procedure or service was performed at the same time as another procedure or service. It can be applied only if there is a clear relationship between the two procedures, such as performing both surgeries on an injured limb and replacing damaged tissue with a graft. The following are some examples of how modifier 25 should not be used:

Conclusion

If you are denied, the most common reason is that the physician did not follow all of the rules correctly. This can affect a lot of different codes and scenarios, so it’s important to be familiar with each one. The key takeaway here is to make sure your documentation is accurate and complete before submitting claims for reimbursement.

In Order to avoid the denial claims there are some major repeated errors taken places.

Following Reasons:

• CLAIMS WITH MISSING INFORMATION
• CLAIMS NOT FILED ON TIME
• NON-SPECIFIC CLAIMS
• ILLEGIBLE CLAIMS
• CLAIMS BELOW PAYER STANDARDS

Payers use specific criteria to determine whether or not services provided to patients are medically necessary. Treatments, prescriptions, or procedures that do not meet the criteria for being medically necessary are typically not reimbursed by payers. Here’s a closer look at what your practice should be aware of.

Cigna provides a good definition of medical necessity. Their definition refers to services provided to patients by physicians using clinical judgment, and those services must be for diagnosing, treating, or evaluating a disease, injury, illness, or the symptoms of those problems. Cigna also states that services should be clinically appropriate in terms of location, extent, duration, and frequency.

Understanding Medical Treatment and Medical Necessity:

CMS allows Medicare Administrative Contractors (MACs) to determine whether services provided to Medicare beneficiaries are medically necessary. Original Medicare is assisted by 12 Medicare Part A and B MACs (Medicare Parts A and B). In addition to processing Medicare Part A and Part B claims, four of these MACs also process home health and hospice claims. There are four MACs specialized to durable medical equipment (DME).

MACs use the following criteria to determine whether services or items are medically necessary:

• It is not an investigational or experimental study.
• It is both effective and safe.
• When ordered and delivered by qualified personnel, it is appropriate.
• Provided in accordance with accepted medical practice standards.
• Provides for a patient’s medical needs in a setting appropriate to the condition and the patient’s medical needs.

Medical Necessity is driven by Diagnosis One of the key criteria driving medical necessity, from the payer’s perspective, is a patient’s diagnosis. The complexity of your medicaldecision-making may be a reliable substitute for the broadly defined idea of medical necessity, as it is based on the number and form of clinical difficulties as well as the risk to the patient.

Medical necessity is determined by providers using evidence-based medical data. The information could be used to request additional testing to diagnose a condition or to order additional procedures to treat that condition.

Clinical conditions and diagnosis codes are used by payers to determine medical necessity. When preapprovals are required, the procedure to be performed as well as the patient’s diagnosis must be submitted. Providers must also explain the severity of the patient’s diagnosis, any previous diagnostic studies or interventions, and the risk of not performing the ordered procedure.

Providers, billers, and coders must all be on the same page when it comes to medical necessity. WS specializes in medical billing and coding, assisting practices like yours in avoiding claim denials. If you’re worried about denials or want to increase your practice revenue, contact WWS today to find out how we can help.

Unless you’re a healthcare worker using durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS) or are a home healthcare company, you probably have no idea what Medicare’s DMEPOS Competitive Bidding Program (CBP) is or how it affects healthcare equipment suppliers and patients.

Frankly, it’s been a thorn in the sides of many DMEPOS companies for years. Imagine their glee when the Centers for Medicare & Medicaid Services (CMS) proposed changes to the program.

All Medicare Durable Medical Equipment, Prosthetics, Orthotics, & Supplies (DMEPOS) Competitive Bidding Program contracts expired on December 31, 2018. As of January 1, 2019, there is a temporary gap in the entire DMEPOS Competitive Bidding Program that CMS expects will last until December 31, 2020. 

During the temporary gap, any Medicare enrolled DMEPOS supplier may furnish DMEPOS items and services to people with Medicare. In most cases, people with Medicare won’t need to switch suppliers on or after January 1, 2019. 

• Medicare beneficiaries may receive DMEPOS items from any Medicare-enrolled supplier until such time as new CBP contracts go into effect.
• When competitive bidding resumes, it will be under new program rules, as discussed below.

Future Competitive Bidding Program Rules

In a final rule scheduled to be published on November 14, 2018, CMS adopted a number of “market-oriented reforms” and technical policy changes for future rounds of competitive bidding. According to CMS, the new rules will simplify the bidding process, preserve beneficiary access to items and services, and make the DMEPOS CBP more sustainable.

Of particular note, CMS has finalized its proposed “lead item pricing” methodology. Rather than bid on each item/HCPCS code in a product category for each competitive bidding area (CBA), suppliers will submit a single bid for the item in the product category designated by CMS to have the highest total nationwide Medicare allowed charges.

Proposed Changes Are a Win/Win

According to a CMS Newsroom Fact Sheet, “Beginning on January 1, 2019, beneficiaries may receive DMEPOS items from any willing supplier (until new contracts are awarded under the DMEPOS CBP).”

Home healthcare supply companies are breathing a big sigh of relief about the proposed changes.

The proposed changes will benefit to small DME companies by allowing them to market their products and company to providers, facilities, and nursing agencies without limiting their customer base to non-Medicare insurances.

Even though Medicare fee schedule is low, it opens up the market to more customers and creates a fairer playing field for all companies, which will result in better service to beneficiaries.

For those companies who didn’t have contracts due to CBP, but now do, the only downside is they’ll need to jump back through the hoops of government regulations to get their Medicare claims paid.

To learn more about Medicare’s Temporary Gap Period or the future of Medicare Competitive Bidding, follow the link http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/DMEPOSCompetitiveBid/index.html?redirect=/DMEPOSCompetitiveBid/

Items you will need

• Taxpayer identification number
• National provider identifier
• Bank account information
• Form CMS-588
• NSC number, provider transaction access number or Medicare identification number (if already enrolled)

Take a visit to the National Plan and Provider Enumeration System website and apply for a user ID and password.

Check your email for an approval notification from the U.S. Department of Health & Human Services, Centers for Medicare & Medicaid Services. After you have received notification that you have been granted approval via email by CMS, go to the next step.

• Visit the Medicare Enrollment for Providers and Suppliers,
• Medicare Provider Enrollment, Chain and Ownership System, or PECOS, website.
• Log in, download and fill out the security consent form

The security consent form contains separate areas and signature requirements for the supplier organization and employer organization. The data you enter in both sections should be the same if you are requesting approval to submit the enrollment applications, and you are an authorized official employed by the supplier organization. Sign and date the security consent form in both places and mail it to the CMS External User Services Help Desk.

• Check your email for notification that your security consent request has been approved.
• Log in to the Internet-based PECOS system and fill out the enrollment application form CMS-855. Click “Continue” and follow the on-screen prompts to complete the application
• Print a copy of the enrollment application for your records.
• Mail any supporting documentation as recommended by PECOS.
• Print, date and sign the certification statement and mail it to the National Supplier Clearinghouse – Medicare Administrative Contractor within one week.
• Check your email for a notification that your Medicare supplier form enrollment application form was successfully transmitted online.

Wait at least 15 days, then log in to the PECOS system to check the status of your application. If you have supporting documents to mail, count 15 days after you have mailed those documents before you check the status of your application.

Points

• You must be an authorized official of the organization you want to register as a Medicare supplier to complete these steps.
• Allow several weeks to complete the enrollment process. Alternately, you could fill out the paper version of the Medicare enrollment application, form CMS-855S, in lieu of applying online.

CMS recommends users change their PECOS password at least once a year.

What is Medical Necessity?

The first thing you should familiarize yourself with is what criteria payors use to determine medical necessity. Medicare defines medical necessity as “Health care services or supplies needed to diagnose or treat an illness or injury, condition, disease, or its symptoms and that meet accepted standards of medicine.”

To make this determination, claim adjusters should consider the following:

1.  Are the services based on credible, scientific evidence recognized by the medical community?
2.  Are the services clinically appropriate regarding type, frequency, and duration?
3.  Is the service effective for the illness it is treating and not more costly than an alternative service?

This criterion is subjective, and even if the treatment is pre-authorized, the insurance claim can still deny. This is why it is critical to keep thorough clinical notes and record of the patient’s experience throughout his or her time at the facility.

How to Appeal?

Before, you write an appeal letter, gather all of the information you have on the client. Review, the diagnosis, the treatment plan and authorization number that you agreed upon with the case manager, and any clinical notes you have during treatment.

Utilization Review

Utilization reviews bridge the gap between providers, payors and patients. They help ensure that the patient receives the appropriate level of care and that the insurance company will reimburse the provider for their care. Proper case management is critical to insurance reimbursement. This means comprehensive intake assessments, knowledge of the patient’s past and current mental state, and timely follow-up calls to extend treatment, if necessary.

Here are the 4 things you should know before calling for a Prior Authorization:

• Call in the case within 24 hours of admission.
• Gather all of the relevant medical necessity documentation during the intake assessment.
• Monitor the client’s progress and if they need more treatment, call in the request days in advance.
• Stay organized. Keep a record of details and any critical information from the case manager.

Familiarize yourself with the appeal process for the insurance company that you are submitting the appeal too. Similarly, you will also benefit from reviewing the patient’s specific policy, verifying there are not any written provisions that you may have missed during the VOB.

Writing the Appeal

Once you are familiar with the appeal process gather all of the information to support your case, so that you are almost ready to write an appeal. Your letter should be clear and concise, citing specific, evidence-based reasoning as to why the insurer should reconsider the claim.

At the top of the letter, include the client’s name, policy identification number, and the claim number that you are appealing. List the name of your facility and the NPI or Tax ID number. Attach any clinical notes and send the appeal using certified mail, fax or per the insurer’s guidelines.

Understanding medical necessity is an important part of medical billing because it is why an insurance company actually pays for a claim.

Stay connected with us to learn more about Medical Necessity to reverse a denied claims or Email me at support@wonderws.com