“Multiple services” can refer to two evaluation-and-management (E/M) services, a procedure plus an E/M service, or two or more procedures provided by the same physician during a single patient encounter.
It can also mean headaches for physician practices as payers seek to challenge or deny claims even though there is a robust infrastructure within the Current Procedural Terminology (CPT®) nomenclature to allow the reporting of multiple services during a single patient encounter, according to an AMA Council on Medical Services (CMS) report adopted at the 2023 AMA Annual Meeting.
This includes appending a CPT modifier 25 to an E/M service code on a claim to indicate the code is a significant, separately identifiable E/M service by the same physician or other qualified health care professional on the same day of the procedure or other service.
“Its use allows two E/M services or a procedure plus an E/M service that are distinctly different but required for the patient’s condition to be appropriately reported and, therefore, appropriately paid,” the report says.
Nevertheless, “there may be a need to ensure that key stakeholders are well educated on the various reporting options,” the report adds.
“It is essential that both physicians and payers understand the nuanced concepts involved, such as existing CPT nomenclature, how the RUC [AMA/Specialty Society RVS Update Committee] process eliminates overlap of physician work and practice expense between services and procedures, and how appropriate reporting and payment for multiple services can lead to greater value to the patient, improved access to care, increased patient satisfaction, and improved overall patient care,” the report explains.
To this end, the House of Delegates directed the AMA to support:
- Mechanisms to report modifiers appropriately with the least administrative burden possible, including the development of electronic health record tools to facilitate the reporting of multiple, medically necessary services supported by modifier.
- Comprehensive education for physicians and insurers on the appropriate use of modifier 25.
