5 ways to get more of your modifier 25 claims approved

A wave is rolling across the country, threatening to swamp physicians who submit claims with modifier 25. As a DO who practices osteopathic manipulative treatment (OMT), I’m a veteran of dealing with modifier 25 denials and have some tips to help you prevail in appealing denied claims.

First, a refresher on the topic for those who rarely use modifiers. Health care professionals file claims with modifier 25 when they’ve performed a significant, separately identifiable evaluation and management service on the same day as another procedure or service.

Modifier 25 most often is used:

• When you have a bundled service—such as pregnancy coverage—and a patient also presents with a separate condition, such as a urinary tract infection or a hurt foot. In such cases, you can use modifier 25 to notify the insurance carrier that you have addressed something outside the bundle’s scope of coverage.
• To communicate that you performed a separate procedure or service on the same day as an office visit. For example, a patient might present with a skin issue, and you perform a biopsy the same day rather than scheduling a separate appointment on another day.

Increasingly, insurance companies reject claims submitted with modifier 25. At one time, this was a regional problem, largely confined to a few insurers and Medicare. More recently, the problem is popping up all over the nation. For instance, Anthem is continuing to audit claims with modifier 25 despite finding no widespread misuse of the modifier.

Fortunately, there are several things physicians can do to increase their odds of getting claims approved when they are submitted with modifier 25. They include the following:

1. Document the patient visit properly

When using modifier 25, clearly document in your notes that you have provided a separate, identifiable, distinct service. Also note that the work involved in the procedure did not overlap with the work performed during the office visit. Please see the documentation example at the bottom of this article.

This kind of clear documentation is the only hope of successfully appealing a rejected claim that was submitted with modifier 25.

Insurance carriers have focused on modifier 25 as a way of reducing what they’re paying out on patient care. They may perform reviews on every health care provider who uses modifier 25, and wholesale deny any procedures provided on the same date. Or, they may deny the office visit that led you to decide to perform an additional procedure on the same date.

When you appeal the rejection of a claim, there is no guarantee you will be successful. But you substantially improve your odds if you:

• Keep up with your coding and make sure your codes are accurate; and
• Document exactly what you did.

Make sure you use ICD 10 for diagnosis codes, CPT for procedure and E/M codes, HCPCS for injections, and clarifying and ancillary coding from CMS such as G codes. If you’re dealing with a complex presentation—such as a patient with multiple diseases—that fact needs to be reflected in both notes and coding. The complexity of the situation must be obvious to the insurance company reviewer.

2. Look for better ways to capture the details of patient visits

If insurers are consistently rejecting your claims submitted with modifier 25, take a look at how you’re documenting them.

It’s best to document patient visits in an EHR system. Handwritten notes—even if they’re transcribed—sometimes don’t include everything that needs to be recorded.

In my own practice, I use a scribe. That way, when I’m in the room with the patient, I can make sure I am documenting as much of the encounter as possible. Remember, we’re all human—when you walk out of that room, it’s all too easy to forget key details about what you examined or talked about.

Yes, hiring a scribe can increase your costs. But you need to weigh the cost against the benefit of more fully documenting the details of each patient encounter.

3. Use the AOA guide to coding and documentation

When trying to communicate with insurance companies, it helps to speak their language.
The AOA’s “Guide to Coding and Documentation: Osteopathic Manipulative Treatment”—which I co-authored—has templates of appeal letters you can send insurance carriers. These letters are crafted to speak to insurers in the language they use.

The guide can also help you to understand what to put into your notes—and more importantly, how to go about the appeals process.

4. Try to think like an insurance reviewer

Always remember that the insurance reviewer is depending on you to clearly communicate what happened during the patient visit. The reviewer cannot read your mind. You must clearly explain:

• Why you saw a patient/performed a service/completed a procedure
• Why it was important to do these things at the time you did them

I frequently hear from reviewers who complain that the charting they receive doesn’t make sense. A reviewer must be able to start at the beginning and know why you came up with something at the end. If the patient came in with foot pain and you ended up removing their gallbladder, how did you get there?

So, try to help the reviewer get from A to Z.

5. Turn to local and national organizations for help

Unfortunately, many appeals of rejected claims are not successful. In my experience, insurers deny about one-quarter of such appeals. When this happens, your best option typically is to seek assistance from local and national osteopathic organizations.

It can be difficult to tease out why an insurance company rejects a claim submitted with modifier 25. Organizations such as the AOA can give you the long view, helping to clue you in about the possible reasons for the denial. They also can lobby insurers on your behalf, educating them about why you did what you did.

There is power in numbers. If physicians in a region consistently appeal rejected claims that are similar in nature, it is a red flag to the insurance carrier that an issue might exist. I have seen insurance companies change their policies after becoming better-educated about why the use of modifier 25 is appropriate in certain circumstances. For instance, earlier this year Aetna agreed to drop its prior authorization requirement for OMT in five states.

Proper documentation of a claim with modifier 25: An example

The following example has been adapted from the AOA’s Guide to Coding and Documentation: Osteopathic Manipulative Treatment.
CPT code: 98925
Descriptor: OMT; One to Two Body Regions Involved
Vignette: A 25-year-old female presents with right lower neck pain of two weeks duration. Somatic dysfunctions of cervical and thoracic regions are identified on exam.
Description of preservice work: The physician determines which osteopathic techniques are most appropriate for this patient, in what order the affected body regions need to be treated, and whether those body regions should be treated with specific segmental or general technique approaches. The physician explains the intended procedure to the patient, answers any questions and obtains verbal consent for the OMT. The patient is placed in the appropriate position on the treatment table.
Description of intraservice work: Patient is in the supine position on the treatment table. Motion restrictions of C6 and C7 are isolated through palpation and treated using muscle energy technique. Dysfunctions of T1 and T2 are treated using passive thrust (HVLA) technique. Patient position is changed as necessary for treatment of the individual somatic dysfunctions.
Description of postservice work: Postcare instructions related to the procedure are given, including side effects, treatment reactions, self-care, and follow-up. The procedure is documented in the medical record.

Related reading:

Anthem proceeds with Modifier 25 audits, prepayment clinical validation policy

Prior authorization requirement for OMT ends for Aetna patients in five states