pqri measure coding and reporting principles - Indiana Academy of ...

• Physicians and qualified nonphysician practitioners (NPP) should use CPT modifier -25 to
designate a significant, separately identifiable E/M service provided by the same
physician/qualified NPP to the same patient on the same day as another procedure or other
service with a global fee period.
• Common Procedural Terminology (CPT) modifier -25 identifies a significant, separately
identifiable evaluation and management (E/M) service. It should be used when the E/M service is
above and beyond the usual pre- and postoperative work of a procedure with a global fee period
performed on the same day as the E/M service.
• Different diagnoses are not required for reporting the E/M service on the same date as the
procedure or other service with a global fee period. Modifier -25 is added to the E/M code on the
claim.
• Both the medically necessary E/M service and the procedure must be appropriately and
sufficiently documented by the physician or qualified NPP in the patient’s medical record to
support the need for modifier -25 on the claim for these services, even though the documentation
is not required to be submitted with the claim.
• Your Carrier will not retract payment for claims already paid or retroactively pay claims
processed prior to the implementation of CR5025. But, they will adjust claims brought to their
attention.
• Carriers will not pay for an E/M service reported with a procedure having a global fee period
unless CPT modifier -25 is appended to the E/M service to designate it as a significant and
separately identifiable E/M service from the procedure.
PREOPERATIVE SERVICES
§1862(a)(1)(A) of the Social Security Act requires that in order to qualify for Medicare coverage, a
service must be reasonable and necessary for the diagnosis and treatment of illness or injury, or to
improve the functioning of a malformed body member. A preoperative service performed due to hospital
or malpractice protocol cannot supercede this guideline for Medicare coverage purposes. Medicare will
pay for preoperative evaluation and management services, and diagnostic tests if they are medically
necessary and meet the documentation requirements of the service rendered.
CMS Transmittal #1707 – May 31, 2001
A. General--This manual instruction addresses payment for preoperative services that are not included in
the global surgery payment.
B. Non-global Preoperative Services -- Consist of evaluation and management (E/M) services
(preoperative examinations) that are not included in the global surgical package and diagnostic tests
performed for the purpose of evaluating a patient's risk of perioperative complications and optimizing
perioperative care. Medicare will pay for all medically necessary preoperative.
C. Non-global Preoperative Examinations -- E/M services performed that are not included in the global
surgical package for evaluating a patient's risk of perioperative complications and to optimize
perioperative care. Preoperative examinations may be billed by using an appropriate CPT code (e.g.,
new patient, established patient, or consultation). Such non-global preoperative examinations are
payable if they are medically necessary and meet the documentation and other requirements for the
service billed.
D. Preoperative Diagnostic Tests -- Tests performed to determine a patient's perioperative risk and
optimize perioperative care. Preoperative diagnostic tests are payable if they are medically necessary
and meet any other applicable requirements.
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*All CPT Codes, Descriptions, and Two-Digit Modifiers
Only Are Copyright 2006 American Medical Association. GEN 2007 REV 07-01
Copyright 2007 Newby Consulting, Inc.