Practice Management Alert

Question: A patient came in for an office visit with the complaint of shortness of breath (786.05), and after performing a pulmonary function test/spirometry (94375) and a chest x-ray, the physician determines the patient has COPD (496). When billing the office visit (99204) along with 94375, should I put modifier 25 on 99204 before billing?

Oklahoma Subscriber

Answer: Whether you should append modifier 25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) to 99204 (Office or other outpatient visit for the evaluation and management of a new patient ...) when you bill the office visit with 94375 (Respiratory flow volume loop) will depend on the payer you are submitting the claim to and the policies that payer follows.

Reasoning: Services in the Medicine section of the CPT® manual that have XXX global periods should not require modifier 25 on the E/M service that accompanies them. When a code has an XXX global period that means that it has no global period, so modifier 25 wouldn't apply.

Caveat: Correct Coding Initiative (CCI) verbiage in version 7.3 stated that XXX global period procedures were considered the same as zero global day procedures in that they include a mini E/M service as part of the procedure. This was a modification in what the procedures include via CCI, not via CPT®.

What that means: Therefore, depending on the payer you are submitting your claim to, and if they accept the premise that was set forth in this older version of CCI, which has not been reversed since then, your claim may require you add modifier 25 to the E/M service to indicate the service was a significantly separately identifiable service from any small E/M that may go with the pulmonary function test (PFT).