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

May 20th, 2020 - Christine Woolstenhulme, QCC, CMCS, CPC, CMRS
Categories:   Modifiers   Medicare   Documentation Guidelines  
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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

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