SCENARIO: Using Modifier 25

I have received a denial of payment for an office visit when a vaccine was administered at the same visit. Has the coding changed?

A modifier -25 may be required for the office visit when a vaccine is administered. Modifier -25 indicates that the E/M code for the office visit represents a distinct and significant service that is separate from the vaccine administration.

The Centers for Medicare and Medicaid Services (CMS) developed the National Correct Coding Initiative (NCCI) to promote national correct coding methodologies and to control improper coding leading to inappropriate payment in Part B claims. CMS developed its coding policies based on coding conventions defined in the American Medical Association’s CPT Manual, national and local policies and edits, coding guidelines developed by national societies, analysis of standard medical and surgical practices, and a review of current coding practices. Information on these edits can be found here.

The NCCI edits indicate that a vaccine administration and an office visit are unlikely to occur at the same time. To overcome this edit and get paid for both the office visit and the vaccine administration, a modifier -25 must be attached to the CPT code for the office visit. The modifier is inserted into Box 24 D next to the CPT code for the office visit.

 

CMS has realized that the edit on office visits when a vaccine was administered has created some difficulties for providers and has allowed Medicaid agencies to disregard this edit. A provider should contact the state Medicaid agency or Medicaid Managed Care organization to determine whether or not a modifier -25 is required to receive payment for the office visit when a vaccine administration fee appears on the same claim.

Some Medicare Administrative contractors are requiring the use of modifier -25 on fee for service Medicare claims. Medicare Managed Care organizations and commercial payers may also be applying this edit. Additionally, some plans have placed an edit into their payment systems to override the -25 modifier when it is used with an E/M code.

You can support your request for payments by submitting a copy the edit from the NCCI website to demonstrate that modifier -25 can be used to overcome the conflict between the office visit (E/M) and the vaccine administration to allow payment for both services.

The “1” in the column 6 indicates that the -25 modifier can be used to indicate that the service identified in column 2 is separate and significant from the vaccine administration codes identified in column 1. Similar documentation can be obtained for all the vaccine administration codes from the CMS website.

If after submitting the documentation, the office visit is still denied you should contact the specific payer to determine the payer’s requirements around the application of modifier 25.