Where is the CCI Edit with Modifier 25 on E/M?

by  Christine Woolstenhulme, QCC, CMCS, CPC, CMRS
May 20th, 2020

If you are not seeing a CCI edit when reporting an E/M code with a certain procedure, it may be that there is no edit. CMS does not have a CCI edit for every CPT code, however, there are still general coding rules that must be followed. 

The use of Modifier 25 is one example that has general coding guidelines and rules, but there is not a CCI edit for every code it should be used with. This information can be found in the NCCI Edit Manual under Chapter I Section D, Evaluation and Management (E&M) Services. It is understood that an E&M service is separately reportable on the same date of service as a procedure with a global period of 000, 010, or 090 under limited circumstances. 

NOTE: Some MACS such as Palmetto GBA state: "Modifier 25 should not be submitted with E/M codes that are explicitly for new patients only".

There are a few reasons CCI does not contain edits on this rule. One reason is all MAC's do not have the same edits - NCCI does not contain edits based on certain rules because MACs have separate edits. NCCI contains many, but not all, possible edits based on these principles.

If a procedure has a global period of 000 or 010 days, it is defined as a minor surgical procedure. In general, E&M services performed on the same date of service as a minor surgical procedure are included in the payment for the procedure. The decision to perform a minor surgical procedure is included in the payment for the minor surgical procedure, and shall not be reported separately as an E&M service. However, a significant and separately identifiable E&M service unrelated to the decision to perform the minor surgical procedure is separately reportable with modifier 25. The E&M service and minor surgical procedures do not require different diagnoses. If a minor surgical procedure is performed on a new patient, the same rules for reporting E&M services apply. The fact that the patient is “new” to the provider is not sufficient alone to justify reporting an E&M service on the same date of service as a minor surgical procedure. NCCI contains many, but not all, possible edits based on these principles. 

NCCI Policy: Chapter I Section D, Evaluation and Management (E&M) Services

References:

Where is the CCI Edit with Modifier 25 on E/M?. (2020, May 20). Find-A-Code Articles. Retrieved from https://www.findacode.com/articles/where-is-the-cci-edit-with-modifier-25-on-e-m-36604.html

© InnoviHealth Systems Inc

Article Tags  (click on a tag to see related articles)


Publish this Article on your Website, Blog or Newsletter

This article is available for publishing on websites, blogs, and newsletters. The article must be published in its entirety - all links must be active. If you would like to publish this article, please contact us and let us know where you will be publishing it. The easiest way to get the text of the article is to highlight and copy. Or use your browser's "View Source" option to capture the HTML formatted code.

If you would like a specific article written on a medical coding and billing topic, please Contact Us.


contact

innoviHealth Systems, Inc.
62 East 300 North
Spanish Fork, UT 84660
Phone: 801-770-4203 (9-5 Mountain)
Email:
free demo
request yours today
pricing
for any budget
sign IN
welcome back!