Wiki 25: Is it a Separate Service?

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aguelfi

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I need your help. I was asked by my area director to make sure that what I did/do is correct in reference to modifier 25. We have different interpretations of it and he asked that I get other coder's input on it and who better than my fellow HMA buddy.



We had a pt that came into our Urgent Care center w/ a lesion on his arm which was his only complaint and reason for the visit. The doctor did a Comprehensive exam and then decided to do an I&D. I didn't bill for the exam because I didn't feel that this met the requirements for a 25 modifier which is a Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure of other service.

He feels that each pt that is seen needs to be evaluated by the doctor prior to any procedure to determine what needs to be done and that justifies a separately identifiable E&M service and is therefore billable. I don't feel that way, I think it then becomes preoperative unless the patient is being seen or evaluated for another condition above and beyond the PRIMARY reason for the visit, in this case the lesion.


What's your take on this?
 
separate service

I guess I can see where this would go either way. I agree with you that not all visits should include an E/M if they have a procedure. But, in the instance of this lesion, I think they could possibly do an E/M also. They did come in with a lesion, but the decision to do an I&D is made during the exam. That's not a given outcome (of course I don't have the notes).
Any other takers?
 
I agree. Unless the physician knew that he was going to do the I&D up front, then I would charge an E/M as well as the procedure(If all criteria is met).
 
The documentation is what you would expect. It's a history, exam and mdm of a needed I&D. All surgical procedures, minor or major, require some preop care. How do you separate the preop, which is not billable, from the E&M services and bill for an exam. How is this a billable charge? I see it from both sides. I do believe the doctor deserves to be paid for his services and I do think an exam is necessary, I just don't think this is what this modifier was designed to do. Every procedure is designed to have a little E&M included in it, call it the preop. If the doctor doesn't go above and beyond this, I don't believe you have a charge. Is it the MDM that's the deciding factor? I don't know, that's where I need the input. The more the better. I'm interested in everyone's opinion. I know I'm not the only coder out there that thinks this way and I would like to hear from others.
 
I understand that all procedures include some component of an E/M. I think that if the MDM is ultimately where the decision to perform the procedure occurs, then you should be able to code the E/M with mod -25 and the procedure. Just my opinion. ;)

Obviously, if the patient is schedule for the procedure then no E/M should be reported in relation to the procedure.
 
E&M and IUD removal

Would this also apply to remove IUD? Pt comes in w/abd pn, MD decides to remove the IUD. As this is not the primary reason for the visit I believe that a 25 should go on the E&M.
 
I agree with your doctor on this one...

The first thing that jumps out at me is the statement "comprehensive exam", a comprehensive exam is not included in any procedure RVU that I am aware of.

The second thing is the intent of the visit. The patient came in because of a lesion. I&D is not the default treatment for every patient with a lesion and since this was a new problem to this provider the intent was to be evaluated and determine a course of treatment.

I think this scenario is a good example of why there is a 25 modifier. He could have told the patient to schedule an appointment with their regular doctor to have the procedure done but he chose to do then it instead. I think he clearly provided 2 services.

Just my opinion,

Laura, CPC
 
I am still not clear?

We have the same issue going on here in my hospital in the emergency room where I work. I have one physician who is very thorough and will do a full history and physical on his patient's (comprehensive exam) and proceed to do a procedure. In his case, since I have the documentation to support a separate service, am I justified in coding an separately identifiable E & M code with the '25' modifier or can I only do that if he picks up and treats separate diagnoses with this separate exam as someone (non-certified in coding or billing) has told me.
 
Laura,
Are you saying if he had not done a comp exam then a 25 wouldn't be appropriate? This is what I'm trying to figure out. What exactly makes this separate?
 
No, I think the 25 is appropriate in this situation regardless of the exam elements done. The fact that it was a comprehensive exam just tips the scales even more in my opinion.

I have always been told that the amount of E/M built in procedures is very minimal. Enough so that it can not stand alone and is only related to the area being treated.

Laura, CPC
 
Okay, so -25 shows that the office visit was ABOVE and BEYOND than what a "typical" office visit is for. The lesion scenario, I can totally see what she is saying in that the patient goes in for lesions, gets and I&D, and leaves the office. Say you bill a 99213-- yes, the visit was done and during the visit, a decision to go ahead and treat the leasion was made. MDM was rather low at that point since it was able to made right then and there. Provider also performs the I&D and yes, that is also able to billed. HOWEVER, I see no place for a -25 modifier because the office visit itself was FOR the lesions. Period.

IF...the patient went in and had lesions checked out, and DURING the visit, says, "doc, hey, I got these really bad warts on my feet too-- mind taking a look at them while Im here?" THAT is when 25 can be reported. Because the original office visit for the lesions no longer was JUST for the lesions-- the doc also inspected Patient X's feet. In turn, he can bill with a -25 modifier in order to receive correct reimbursement for BOTH types of service offered in ONE office visit.

Make sense?;)
 
What was the physician's intent when the appointment was made? Was it to have an office visit and evaluate this lesion. If that is the case an E/M is can be billed with 25 modifier and the I&D also. We have this scenerio come up alot in my family practice office and it's all about the intent of the visit. If it was known prior to the visit that and I&D needed to be done, then no an E/M is not warranted but sounds to me like the Dr. decided to do an I&D within his MDM and should bill the e/m. The I&D was not a "planned procedure", with what info we have received from the poster.
 
The -25 modifier indicates separately indentifiable - the evaluation of the lesion (first example) is included in the primary procedure and not separately billable. A provider cannot I&D a lesion without evaluating the lesion - adding an officie visit for the evaluation would be double billing.
For the IUD with ab pain, (second example) since the presenting problem was ab pain, which needed to be evaluated and determine a course of action, I would charge an add'l E/M because the resulting procedure IUD removal, was not what the patient presented for. For the third example, in the ED, just because a provider performs a comprehensive exam does not mean it is medically necessary. Again, if performed to evaluate an issue that would lead to a procedure, then not additonal E/M should be billed. Of course, all my suggestions would need documentation to support any service. With RACs coming to the Midwest soon, we've made some changes in our interpretation of the -25 modifier on the side of being more cautious.
 
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