Health Care
         DEPARTMENT OF HEALTH & HUMAN SERVICES              Financing Administration


  REFER TO: FQA-541                  Memorandum
 Date      AUG 27 1993

From      Director, Bureau of Policy Development
                Director, Bureau of Program operations

 Subiect    Extra documentation Requirements with Modifier 25 Services

           
 To           All Associate Regional Administrators for Medicare


            We have been advised that some carriers--e.g., Pennsylvania,
            Massachusetts, Maryland, and Nevada--are routinely imposing
            additional documentation requirements prior to paying for
            modifier 25 services. You will recall that modifier 25 is
            to be used by physicianS when they are billing for an
            evaluation and management service provided on the same day
            that they provided a minor surgical service to the same
            patient. prior to billing modifier 25, the physician is to
            have determined that the evaluation and management service
            for which he or she is billing is a service which is clearly
            distinct from the surgical service. Once the physician
            makes the determination to bill modifier 25 with an
            evaluation and management service, that service is to be
            paid for. Except as noted below, no other carrier screens
            or documentation requirements are to be imposed.

            The exceptions are that prepayment documentation is or may
            be required with modifier 25:

            o  when inpatient dialysis services are billed (see the
            attached June 12, 1992 memorandum from Charles Booth to all
            ARAs for Medicare),

            o when pre-operative critical care codes are being billed
            for within a global surgical period (see issue 43 in the
            May 29, 1992 carrier Medical Directors' report--which
            describes required documentation that the critical care
            services be unrelated to the surgery), or

            o when a carrier has conducted a specific medical review
            process and determined, after reviewing the data, that an
            individual or a group has high statistics in terms of the
            use of modifier 25, has done a case-by-case review of the
            records to verify that the use of modifier was inappropriate
            and has educated the individual or group.

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       DEPARTMENT OF HEALTH & HUMAN SERVICES               Financing Administration
--------------------------------------------------------------------------------------------------------------------
                                                                                                      MEMORANDUM
    FQA - 541

    Date    JUN 23 1992

    From    Director
                Burueau of Policy Development

    Subject  Payment for Evaluation end Management Services on the same Day
                 as A Procedural Service

                All Associate Regional Administrators
     To      for Medicare


      An you know, we have a policy which does not permit payment
      for evaluation and management services performed on the same
      day as a minor procedural service, unless the evaluation and
      management service is a "documented, separately identifiable
      service."   It has come to our attention that some carriers are
      not paying for such separately identifiable services unless
      they are. "unre1ated" to the procodural service. This is not
      correct. A docunented, separately identifiable  related
      service is to be paid for.  We would define related as being
      caused or prompted by tbe same symptoms or conditions.


                          Kathleen A. Buto


       cc:
       Gary Kavanagh, BPO
       Jean Harris, OFO, BPO
       Office of Field Operations
       Office of Issuances
       Cindy Reed. OFP. BPO

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