Remember these guidelines when coding for Medicare Plus Blue^SM PPO members

Use of Modifier 25

When Blue Cross pays for medical procedures, the payments include certain evaluation and management (or E&M) services that are necessary before you perform a procedure. Additional payments for these E&M services performed by a provider on the same day as a procedure are not allowed according to the Global Surgery Package Policies.

Modifier 25 is used when a provider performs an E&M service on the same day as a procedure that is significant, separately identifiable, and above and beyond the usual pre- and post-operative care associated with the procedure. Using modifier 25 in these situations allows additional payment for the separate E&M service.

An E&M service isn’t needed and shouldn’t be reported at every patient encounter. While the use of modifier 25 does not require different diagnosis codes, when patients have repeated visits and procedures for the same conditions, our system won’t allow a modifier 25 to override the visit edit and allow payment for the E&M without a record review. This helps us ensure that the E&M being reported is separate from the procedure and the prior visit.

Anesthesia for pain management procedures

We are in the process of reviewing and enhancing clinical editing related to anesthesia provided for pain management procedures. Anesthesia and moderate sedation services (CPT codes *00300, *00400, *00600, *01935-01936, *01991-01992, *99152-99153, *99156-99157) will be subject to a clinical edit when reported with a pain management service, but without a surgical procedure, for patients 18 years of age or older.

In 2016, the American Society of Anesthesiologists noted that while there are select indications for patients to receive anesthesia with interventional pain procedures, many patients are able to undergo these procedures without receiving anesthesia. Our enhancement of the clinical editing is in line with the ASA statement and should be in effect this month.

There are no changes to authorization rules for pain management procedures. Please refer to authorization guidelines if you have questions.

Reporting laser treatment

CPT codes *96920-96922 are laser treatments that are specific to the inflammatory skin disease (psoriasis). In accord with the code description, we will apply an edit for any claims reported without a diagnosis of psoriasis or parapsoriasis. This change will be effective for dates of service beginning Aug. 1, 2018.

In line with this change, please ensure that your documentation and coding supports the services rendered to minimize and hopefully eliminate edits. As always, if you receive an edit that you believe is incorrect, you can file an appeal through the clinical editing appeal process.