March 3, 2025

Regence Modifier 25 Policy Update

IMA is pleased to announce that Regence Blue Shield of Idaho made the decision to not implement changes to Modifier 25; Significant, Separately Identifiable Service (Administrative #103) and Global Days (Administrative #101) reimbursement policies. The proposed policy changes would have reduced E/M reimbursement by 50%. Instead, the policy language reverted back to the July 1, 2023 version stating the following:

All surgical procedures and some procedural services include a certain degree of physician involvement or supervision which is integral to that service. For those procedures and services a separate E&M service is not normally reimbursed. However, a separate E&M service may be considered for reimbursement if the patient's condition required services above and beyond the usual care associated with the procedure or service provided. To identify these circumstances, modifier 25 is attached to the E&M code.

• Outpatient hospital procedures and services with status indicator of "S" or "T" include some pre-procedure work, such as obtaining the patient's blood pressure, temperature, asking the patient how he or she feels, and written consent to perform the procedure. For those procedures and services, a separate E&M service is not normally reimbursed. However, a separate E&M service may be considered for reimbursement, if the patient's condition required services above and beyond the usual care associated with the service provided. To identify these circumstances, modifier 25 is attached to the E&M code.
• The submission of modifier 25 appended to an E&M ode indicates that documentation is available in the patient's records that will support the significant and separately identifiable nature of the E&M service.
• Modifier 25 should not be appended to an E&M code used in conjunction with a Major Surgical Procedure (code having a global period of 90 days) unless there is also an unrelated minor surgical procedure performed.
• Modifier 25 should be appended to E&M codes used in conjunction with a Minor Procedure (code having no preoperative period and a 0 or 10 day global period).
• Modifier 25 should be appended to outpatient E&M codes as well as emergency department (ED) codes (code 99281-99285) when provided on the same date as a procedure or service that has a status indicator of "S" or "T".

Upon learning of the potential policy change, IMA and Independent Doctors of Idaho (IDID) sent a joint letter to Regence explaining the impact on patient access to care such a change would generate. IMA thanks Gill Compliance for providing an in-depth analysis of the potential impact of the cuts, and the many physicians who reached out to Regence individually. Your advocacy efforts made a significant difference on this policy decision. IMA also extends our gratitude to Regence representatives for their consideration of input from Idaho's medical community.

IMA will stay vigilant with payor policies on behalf of our members, especially this year, as we expect more changes to come. This is a great reminder of why your IMA membership is so valuable!

Click HERE to view Policy #103

Click HERE to view Policy #101

Idaho Physician Educates, Urges Vaccination in Response to Texas Measles Outbreak

A measles outbreak originating in West Texas has grown to nearly 150 cases and has resulted in the first U.S. death since 2015 from the respiratory disease. Vaccination rates have declined nationwide since the COVID-19 pandemic, and most states are below the 95% vaccinated threshold required to protect communities from this highly transmissible disease.

Idaho is no exception to this decline in measles vaccination status. A recent opinion piece by pediatrician and IMA member Noreen Womack, MD, cited childhood measles, mumps, and rubella (MMR) vaccination rates for Idaho kindergartners at 81%. Dr. Womack's piece, published in the Idaho Capital Sun, urges Idahoans to check their immunization records to ensure that they and their children are fully immunized, noting that two doses provide 97% immunity against measles.

In a recent Fox News segment, HHS Secretary Robert F. Kennedy characterized the Texas outbreak as "a call to action for all of us to reaffirm our commitment to public health." In a written statement aired in the segment, Kennedy wrote: "The decision to vaccinate is a personal one. Vaccines protect individual children from measles, but also contribute to community immunity, protecting those who are unable to be vaccinated due to medical reasons."

The IMA Public Health Committee is actively monitoring this situation and working to ensure that Idaho physicians have access to the necessary resources to keep patients safe and informed.

Healthcare Compliance Webinar Series

IMA is pleased to cosponsor Holland & Hart's complimentary 13-part Healthcare Compliance Webinar Series beginning at noon Mountain Time, Thursday, March 6, and continuing through mid-September.

Remaining compliant in today's ever-changing healthcare landscape is critical to healthcare providers. These one-hour webinar presentations, designed for professionals in the healthcare and life sciences industries, will provide overviews and updates on critical laws and regulations as well as practical guidance for applying the laws. Visit the link below to register for the program(s) you are interested in. Topics include Fraud and Abuse Laws, EMTALA, HIPAA, Substance Use Disorder Records, and the Information Blocking Rule.

CLICK HERE to RSVP

Noridian E/M Office Services; Top Provider Q&A Part 1 

A collaborative of inquiries from the Medicare Administrative Contractors (MACs) in conjunction with the Noridian Provider Outreach and Education department over top provider questions was released on various local contractor websites last year. The intent was to ensure consistent communication and education so that providers have updated or clarifying information about E/M services for appropriate documentation and claims submission. In Part 1 of this article, we will cover some of the highlights involving E/M documentation, number of problems addressed, and data complexity clarifications.

Q: Under the 1995/97 CMS E/M guidelines, providers were held to specific criteria of history, exam, and medical decision making for the level of services provided. Yet, under the 2021 American Medical Association (AMA) E/M guidelines the level of service criteria shifted strictly to medical decision making or time. Will the medical record still require history and an exam?

A: Documentation must show the medical necessity of the service. This is the diagnosis or treatment of an illness or injury or treatment of a malformed body member. The guidelines indicate you perform the history and exam as clinically appropriate. Your documentation must support the medical necessity of the service and the level of service chosen. While the nature and extent of history and exam is determined by the provider and is not an element in code level selection, both should tell the patient's story, be medically relevant, and correlate with any presenting complaints.

Q: The first component of medical decision making (MDM) is the number and complexity of problems addressed at the encounter, which involves a disease, condition, illness, injury, symptom, sign, finding, complaint, or other matter that is evaluated and/or treated at the encounter by the provider reporting the service. If the patient has more than one problem, can I increase the number of problems addressed to a higher level?

A. No. Some of the bullets under the number of problems addressed indicate '1 or more'. This would mean that the additional problems in that bullet would still count for one bullet. some of the bullets indicate '1'. Choose your level based on the problem(s) addressed and the highest level or problem(s) indicated. Look to the other two elements, data and risk, to determine if a higher level of services is appropriate. In addition, when multiple problems are listed in the same range of medical complexity, this does not bump the problems addressed to a higher level. For example, if the patient has an acute, uncomplicated illness and a stable chronic condition, the problems addressed level is low and does not bump to moderate.

The second component of MDM, the amount and complexity of data to be reviewed and analyzed contains three different categories that are weighted differently when assigning credit and have a lot of AMA rules or clarifications. Here are a couple of additional clarifying Q&As:

Q: The patient brings a log of their food intake, blood pressures, blood sugars, etc. Can I count this as "external notes"?

A. No. Reviewing notes from another unique source data category 1) would be notes from another health care professional or organization. When choosing your level of service based on time, you can count the time spent reviewing the log.

Q: I reviewed the uploaded results of tests ordered by an external entity onto the patient's medical record. Can I count the review of this unique test?

A: Since the practitioner or a member of your group with the same specialty did not order the service, you could count this as a review of a test. If the test was part of an external note, you would only count the review of the external note. Documentation must show you reviewed the results and used those results in the medical decision-making for the patient.

Q: The medical record contains test results. Does this mean I can count the review of the tests?

A: Document your review/analysis of the test results. Your documentation must show your review and use for your medical decision for that patient encounter. If you submit a separate charge for the professional component of the test or use the independent interpretation as a data element, do not count the review.

Next month in Part 2, we will cover some highlights from the Q&A involving time, risk and miscellaneous questions.

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