All E&M services provided on the same day as a procedure are part of the procedure and WellCare only makes separate payment if an exception applies.
Modifier 25 is used to describe a significant, separately identifiable E&M service that was performed at the same time as a procedure.
CMS and the OIG have documented that modifier 25 is one of the most frequently misused modifiers by medical providers. WellCare may require medical records prior to payment for E&M services to which Modifier 25 is appended in certain situations to validate that the documentation demonstrates that the E&M service is significant and separately identifiable.
A member's medical documentation must clearly show that the E&M service that was performed and billed was unique and distinct from the usual pre-operative and post-operative care associated with the primary procedure performed on the date of service.
Providers should reference the NCCI Policy Manual for guidance on correct submission of modifier 25.
Place of Service Coding
According to CMS policy, the place of service code used should indicate the setting in which the patient received a face-to-face encounter or where the technical component of a service was rendered, in the case of an interpretation. However, when a patient is in a registered inpatient status, all services billed by all providers should reflect and acknowledge the patient's inpatient status.
When a physician/practitioner/supplier furnishes services to a registered inpatient, payment is made under the Physician Fee Schedule at the facility rate. A physician/practitioner/supplier furnishing services to a patient who is a registered inpatient shall, at a minimum, report the inpatient hospital POS code 21 irrespective of the setting where the patient actually receives the face-to-face encounter.
WellCare policy requires all providers to use POS 21 when providing services to a patient who is a registered inpatient, regardless of the site where the patient physically receives the service.
Providers should reference MLN Matters MM7631 for place of service coding instruction.