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PM Rev. A-01-80, Use of Modifier -25 and Modifier -27 in the Hospital Outpatient Prospective Payment System (OPPS)

Program Memorandum

Department of Health and Human Services (DHHS)

Intermediaries

HEALTH CARE FINANCING ADMINISTRATION (HCFA)

PM Rev. A-01-80, Use of Modifier -25 and Modifier -27 in the Hospital Outpatient Prospective Payment System (OPPS)

Date: JUNE 29, 2001

CHANGE REQUEST 1725

JECT: Use of Modifier -25 and Modifier -27 in the Hospital Outpatient Prospective Payment System (OPPS)

This Program Memorandum (PM) provides clarification on reporting modifier -25 and modifier -27 under the hospital OPPS.

The Current Procedural Terminology (CPT) defines modifier - 25 as “significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service.” Modifier -25 was approved for hospital outpatient use effective June 5, 2000.

The CPT defines modifier -27 as “multiple outpatient hospital evaluation and management encounters on the same date.” HCFA will recognize and accept the use of modifier -27 on hospital OPPS claims effective for services on or after October 1, 2001. Although HCFA will accept modifier -27 for OPPS claims, this modifier will not replace condition code G0. The reporting requirements for condition code G0 have not changed. Continue to report condition code G0 for multiple medical visits that occur on the same day in the same revenue centers.

For further clarification on both modifiers, refer to the CPT 2001 Edition. Below are general guidelines in reporting modifiers -25 and -27 under the hospital OPPS.

General Guidelines for Modifier -25

A. Modifier -25 should be appended only to evaluation and management (E/M) service codes within the range of 92002-92014, 99201-99499, and with HCPCS codes G0101 and G0175.

B. To append modifier -25 appropriately to an E/M code, the service provided must meet the definition of “significant, separately identifiable E/M service” as defined by CPT.

C. Although we stated in Transmittal A-00-40 that Medicare requires that modifier -25 “always be appended to the Emergency Department E/M codes when provided . . .” the Outpatient Code Editor (OCE) only requires the use of modifier -25 on an E/M code when it is reported with a procedure code that has a status indicator of “S” or “T.” Nevertheless, such an edit does not preclude the reporting of modifier -25 on E/M codes that are reported with procedures codes thatAlthough we stated in Transmittal A-00-40 that Medicare requires that modifier -25 “always be appended to the Emergency Department E/M codes when provided . . .” the O

Note the OCE will continue to process claims for those procedure codes that are assigned to other than “S” or “T” status indicators if it is reported with an E/M code and a modifier -25.

HCFA-Pub. 60A

General Guidelines for Modifier -27

A. Modifier -27 should be appended only to E/M service codes within the range of 92002-92014, 99201-99499, and with HCPCS codes G0101 and G0175.

B. Hospitals may append modifier -27 to the second and subsequent E/M code when more than one E/M service is provided to indicate that the E/M service is “separate and distinct E/M encounter” from the service previously provided that same day in the same or different hospital outpatient setting.

C. When reporting modifier - 27, report with condition code G0 when multiple medical visits occur on the same day in the same revenue centers.

As is true for any modifier, the use of modifiers -25 and -27 must be substantiated in the patient’s medical record.

Fiscal Intermediaries should forward this PM electronically to providers and place on their web site. This PM should also be distributed with your next regularly scheduled bulletin.

The effective date for this PM is October 1, 2001.

The implementation date for this PM is October 1, 2001.

These instructions should be implemented within your current operating budget.

This PM may be discarded after October 1, 2002.

If you have any questions, contact your regional coordinator.

 

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