Wiki E/M Modifier 25

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murph542

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Hi, I’m auditing BH for Virginia Medicaid. I’m reviewing BH providers who bill for med management as 99214/99215 and add-on codes for psychotherapy as 90936/90837. My question is on whether modifier 25 is needed on the E/M codes when billing the psychotherapy add-ons? One provider is using it for every claim that has both codes, but the majority of providers have not been using it. I thought you didn’t need modifier 25 since the 90836/90837 codes are add-on codes. Can anyone provide some insight either specific to Medicare or Virginia Medicaid? And if possible, links to official guidelines I can use for citations in my reports. Thank you!
 
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Agreed on the modifier 25 issue - I run into this often where a provider just blanket bills all of their E/Ms with the 25 modifier. On the add-on codes, what sort of documentation are you seeing to show that it's separate and distinct from the E/M? I tend to see very little to support a full E/M when I run into these.
 
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Jennifer.White@atg.in.gov said:
Agreed on the modifier 25 issue - I run into this often where a provider just blanket bills all of their E/Ms with the 25 modifier.
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Yikes, that sort of billing pattern could trigger an audit.

Jennifer.White@atg.in.gov said:
On the add-on codes, what sort of documentation are you seeing to show that it's separate and distinct from the E/M? I tend to see very little to support a full E/M when I run into these.
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I'm not sure I understand this question. An add-on code is always performed with a primary service. Is the issue that the E/M documentation isn't there?
 
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jkyles said:
Yikes, that sort of billing pattern could trigger an audit.


I'm not sure I understand this question. An add-on code is always performed with a primary service. Is the issue that the E/M documentation isn't there?
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Yes, it did indeed trigger an audit.

On the documentation, there was enough evidence to support the psychotherapy (counseling), but the E/M was documented as just very basic - they took vitals and confirmed they were taking their meds. To me, that doesn't read as enough documentation so I was wondering what sort of things you see as documenting a separate and distinct service for the E/M portion.
 
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