25 modifier w/ov, new pt.

[Willingham]

Can someone share with me if you are aware, whether or not the 25 modifier is acceptable with a new office visit? I read early part of the year that the
OIG had audited and cited a high error rate when using this modifier with an ov for a new pt. because the new-pt visit is by definition a stand-alone billiable visit. Any thoughts of this???? thanks. Also when coding this ov with a procedure the CCI edits tells you, you need to append the 25 to pass the edit. ????????????????????

[coder911]

If the documentation supports billing both an E/M visit and a procedure code - then by all means append the modifier 25. It specifically applies to E/M coding and therefore is applicable in this case. I don't think that only new patient E/M services have been targeted. I've read many an article that generally "harps" on the OIG zeroing in on modifiers 25 and 59. Simply because they override edits and get extra payments that might not have been "earned" properly.

---But as long as you're covered in the dictation, then bill it with modifier 25.

[thompsonsyl]

Hi....after reading your initial question I researched using -25 modifier on new patient visits & OIG's restriction on this because I'd never heard it said that new visits couldn't be appended with this modifier. Low and behold, I did find it in "black and white", so to speak.

http://www.mpro.org/news/pdf/articles/rmc011606.pdf

It had always been my understanding that use of modifier -25 was appropriate if a "significantly identifiable" E/M service was also rendered and documented on the same DOS; even if a patient is "new". I mean what if a patient comes in for impacted cerumen and then decides to have a wart cryo'd on his finger?

Now I'm second guessing myself too...I'm eager to see what other coders will respond to your question.

[Willingham]

to coder 911, I understand the rule for applying mod.25 and that is for ov but, I was trying to find out if in deed it is justifiable with a new pt.visit, thanks anyway.

[blackiez1]

I do auditing and see this all the time. It would appear to me that it IS inappropriate to append a 25 modifier on a new patient visit. It does not affect anything.
Think about it: The provider has never seen this patient before; therefore, any procedure performed is ok without the 25, because there is not an established history with the patient to indicate anything was significantly, seperately identifiable from the e/m service. 25 is grossly misused by applying it to a new pt ov, it is all fair game on the first visit. New patient never been seen; new problem. The 25 modifier does not have to be appended to get reimbersment for a procedure performed on a new patient.
We need to remember: Modifiers are there to indicate a procedure was a modified from its original course.
There is no modification on a new patient visit. The dr has no idea what is coming in the door when the patient arrives for the first visit; therefore, nothing to modify.
This how we review our new pt ov for fraud.

[raelewlov]

Yes, that is true, but I have gotten claims denied for new patient or new consult from medicare and other insurance without the modifier 25. I have had to submit appeals with corrected claims.

[SScoder]

I would be concerned about using information to validate the non use of modifier 25 to NP from a source other than Medicare, AMA, CPT or NCCI.

The informatin from the ATLANTIC INFORMATION SERVICES,Inc. states at the bottom that they "are not affiliated with any government agency" etc..

Look at the CMS Manual, Pub 100-4 Medicare Claims Processing, Transmittal 954.

I will continue to use modifier 25 as long as it is "significant an Separate" according to the Medicare , AMA, and CPT guidlines.

Hope this helps and have a great day!!

[tekocz04]

Hi, From what I learned recently on my externship, a modifier 25 (problem oriented) is appropriately appended second after the initial visit (i.e., physical exam)--you'll get more revenue for the physical and probably half (depending on insurance carriers) on the mod-25 visit. Hope I explained this correctly. New to coding but have more confidence after billing/coding from encounter former and documentation.


Terry
CPC-A
tkoczor767@aol.com

Originally Posted by Willingham

Can someone share with me if you are aware, whether or not the 25 modifier is acceptable with a new office visit? I read early part of the year that the
OIG had audited and cited a high error rate when using this modifier with an ov for a new pt. because the new-pt visit is by definition a stand-alone billiable visit. Any thoughts of this???? thanks. Also when coding this ov with a procedure the CCI edits tells you, you need to append the 25 to pass the edit. ????????????????????

[00032036]

If You End Up Doing A Procedure Of Any Kind Along With The First Visit You Need To Use The Modifier 25 On The E/m. Dale In Salmon, Idaho

[Lisa Bledsoe]

I have never heard of not using modifier 25 on an E/M if it is separately identifiable from the procedure performed. You could certainly see a new patient for an URI and remove a lesion at the same visit...for which modifier 25 would be appended to the E/M.