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Wiki Modifier 25

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jennlester71

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Lebanon, TN
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I barely just started school for coding, but I have had some experience with codes in general when doing insurance verification, precerts, and cost estimates. Now I am in training sending out clinic charges. I believe sometimes we use the modifier 25 when it may not be appropriate. We have stopped using it and removed the office E/M code for some things, but for other similar things we are still using it.

I am afraid to push the "powers that be" on it because "they" were very adamant about using it. Even when I brought up the "what if scenario" of "What if the patient has the consult regarding this procedure and a week later comes in for the procedure/injection itself" Everything I've read from Cigna, BCBS, UHC, all disallow the modifier 25 simply to bypass an edit and that the procedure code serves as it's own E/M code, that using a separate E/M code with modifier 25 is only supposed to be used if there is a significant, separately identifiable E/M service above and beyond the other service provided.

What ethical responsibility to I have in this? I don't want to jeopardize getting my certification over this. I also don't want to jeopardize my job and be some sort of pariah.
 
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SharonCollachi said:
If a patient has an office visit/E&M, then comes in a week later for the procedure/injection, then you do not bill another E&M on the day of the procedure, UNLESS something happened in the meantime that would warrant a separate E&M (which would not be a frequent occurrence).
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I agree with your answer. I am just at a loss how to fight back on this. And honestly don't know how much more I can say on here for fear of even asking this on a public forum. What responsibility do I have when my higher ups are insisting on doing it their way? --Because I specifically asked, ok, what if the consult for this is like a week before. And the answer was that the doctor goes in the room, consults etc, but still the injection code from what I understand is already considered it's own E/M, the doctor explaining the procedure, all the things, etc. I completely agree with you and I don't feel comfortable putting the 99XXX code with the modifier. Yikes...
 
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