Stacey A. Borowicz

CGS Changes Coding Requirements and Clarifies Modifier-25

July 3, 2012Articles
Evaluation and Management Services Coding

On May 10, 2012, CGS Administrators, LLC, the Medicare Administrative Contractor for Medicare Parts A and B in Ohio and Kentucky, announced that providers must perform and document all three elements of an Evaluation and Management (E&M) service in order to bill for any code higher than CPT 99211, the lowest subsequent office visit. The final coding level should still be assigned based on the highest two of the three elements.

The healthcare community is well aware that documentation of E&M services includes three elements: patient history, physical exam, and medical decision-making. Before CGS’ May 10 update, providers could code and bill E&M services based on the performance and documentation of any two of the three E&M elements. For example, at a follow-up E&M visit for a prescription refill, a physician could perform and document only the patient history and medical decision-making components commensurate with a level 3 visit and then bill for a CPT 99213. Historically, the physician did not need to perform or document the third E&M component (e.g., physical exam). This is no longer acceptable.

Now providers must perform and document all three elements of an E&M service to justify their coding and billing. This means that providers must perform and document at least a minimal third E&M element at every follow-up visit. CGS will downgrade any claim that is not supported by documentation of all three E&M elements to CPT 99211 and its accompanying lower reimbursement.

Make certain that your EMR templates and other billing policies are revised to meet this new requirement.

The full May 10 CGS posting on this subject can be viewed here.


On May 14, CGS clarified proper use of Modifier-25 with respect to the global surgery indicator “XXX.” CGS states that a Modifier-25 should ONLY be used to designate a significant and separately identifiable E&M service that was performed by the same physician on the same day as another procedure or other service. The E&M service may be related to the same diagnosis as the XXX procedure but cannot include any work inherent in the performance, supervision, or interpretation of the XXX procedure.

A Modifier-25 cannot be used when the E&M visit is an inherent and necessary part of the surgical procedure. For example, a physician cannot use a Modifier-25 when performing an infusion procedure at an office visit because such an E&M visit is a necessary part of the infusion. In this example, the infusion procedure and E&M visit are bundled and reimbursed as one service.

CGS warns against any attempts to circumvent the rules by conducting an E&M visit on a different day than the underlying XXX surgical procedure just so the provider can bill for the E&M service in addition to the XXX surgery. CGS considers this type of “unbundling” inappropriate and will deny payment for the delayed E&M visit upon any subsequent audit of the documentation.

The full May 14 CGS posting on this subject can be viewed here.

*Dinsmore would like to acknowledge and thank MaryAnn Baughman of Healthcare Coding Consultants, Columbus, Ohio, for her contribution to this alert.