Wiki modifier 25

[nics1011]

Hello all!

I understand that insurance companies are cracking down on the use of modifiers as well as the billing for E/M visits. I have to admit I am a little confused on when it is appropriate and when it is not appropriate to use modifier 25 with an E/M...

Is is right to believe the following:

New patient with injection=E/M + Injection code but no modifier necessary
Established patient being seen for new problem with an injection=E/M + modifier + injection code
Established patient being seen within the last 6-12 months for the same diagnosis receiving an injection =injection code BUT NO E/M as it is included in the procedure code
Established patient seen more than a year ago no being seen with an injection=E/M + modifier+ injection code

I look forward to your assistance in this issue. = ) = )

 

[WendyJeann81]

Per CMS Website Regarding Mod 25

Definition: Significant, separately identifiable evaluation and management (E/M) service by the same physician* on the day of a procedure

*Same physician - Medicare regulation states: "Physicians in the same group practice who are in the same specialty must bill and be paid as though they were a single physician."

All E/M services provided on the same day as a procedure are part of the procedure and Medicare only makes separate payment if an exception applies.

Appropriate Usage
•Modifier 25 indicates that on the day of a procedure, the patient's condition required a significant, separately identifiable E/M service, above and beyond the usual pre and post-operative care associated with the procedure or service performed.
•Use Modifier 25 with the appropriate level of E/M service.
•The procedure performed has a global period listed on the Medicare Fee Schedule Relative Value File. This global period could be 000, 010, or 090 days.
•An E/M service may occur on the same day as a procedure and within the post-operative period of a previous procedure. Medicare allows payment when the documentation supports the 25 modifier and the 24 modifier (unrelated E/M during a post-operative period.)
•Use Modifier 25 in the rare circumstance of an E/M service the day before a major surgery that is not the decision for surgery and represents a significant, separately identifiable service.

Inappropriate Usage
•A physician other than the physician* performing the procedure.
•Documentation shows the amount of work performed is consistent with that normally performed with the procedure.

The following statements are false
•I can always use this modifier when I did not plan the procedure.
•I can always use this modifier when the diagnoses are different.
•I can never use this modifier when the diagnoses are the same.

 

[iowagirl77]

I agree, it is confusing! I haven't seen anything that refers to the time frame of 6-12 months; I don't think your assumption on that is correct. We have patients that may only come in once a year, but it is always for a repeat injection. Since that really requires no substantial decision making, a separate E/M isn't supported because the circumstances and plan of care has not changed. We've been through this with our providers over the last year that often bill repeat injections and had been in the habit of billing an E/M with it.

Some things to consider that might support a separate E/M:
-Has the plan of care changed? Are they going to try a different kind of drug because the last one injected was ineffective?
-Has the condition worsened? Is there good documentation showing increased MDM due to this?
-Is the patient also seen for an unrelated condition that shows enough documentation to support an E/M on it's own?
-Has the patient been seen for this issue previously, but the decision/plan of care was made today to do the injection?

Some things that may indicate a separate E/M is NOT supported:
-Repeat injection of same area
-Patient has come in requesting the injection or the injection was already ordered

A good article on this can be found at https://www.aapc.com/blog/27185-use-caution-when-reporting-same-day-injection-and-em/

I hope that helps!

Susan