Wiki 25 modifier - should be coded

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I'm having trouble with the 25 modifier. I'm being told certain codes are included in an E&M, such as a blood draw 36415, And not to append a modifier 25. In the past I've had whole claims denied for not adding a 25 modifier so this would indicate that I should only code the E&M? I was taught if a service/procedure was done, it should be coded. If this is the case, how would I code this visit? Would it be coded with an E&M only?
I've also had immunizations with E&M denied unless a 25 mod is used (for example in a case of well child visit), but I'm now being told I don't have to use the 25 modifer.
If a patient comes in for a sore throat and the provider does a full hpi & exam, takes a strep test and determines it is strep and gives a penicillin injection, what would I code? Should I only code the injection w/o the E&M? or the E&M with out the injection? How about the rapid strep test? Is that included in the E&M?

So I guess my question is, what IS and IS NOT included in the E&M?

I appreciate any insight you can give me, thank you.
 
25 modifier depends on what service is performed along with E&M. In general if a minor procedure is perfomed along with E&M then we need to give 25 mod.
E&M with minor procedure - 25 mod
E&M with major procedure - 57 mod
E&M with lab services - No 25 mod
E&M with vaccinations or injections - 25 mod
E&M with Radiology - No 25 (but it also depends on payer)

Hope this helps.

Thanks.
 
You really need to look at the NCCI edits to see what is bundled, some codes if thats what the patient was seen for you can not append a modifier, you (meaning everyone) should educate themselves and other staff members on NCCI edits. You can find them through the CMS website. Remember you need to justify the modifier not just out it on to get paid.

Just My Opinion
 
Each code (injection, blood draw, minor procedure, etc.) comes with its own set of "what's included." (Unfortunately, neither the AMA nor CMS has, to my knowledge, put this information out there in a way where it is "findable.") So you will bill an E/M with the 25 modifier any time the provider does something above and beyond the "what's included" for that code. Here are a few examples that I have been able to gather:

96372 (I/M or sub-Q injection): Confirmation of the order for the injection and supervision of the staff who perform it. (Note that this code does NOT include an HPI, exam, and decision to order the injection!)

17000 and 17110 series (destruction of benign and pre-malignant skin lesions): The destruction procedure, plus review of pertinent medical records data, discussion of treatment choices, review of risks of the treatment with the patient, obtaining informed consent, preparation of necessary equipment, inspection and palpation of lesions to establish a diagnosis and to specify size/depth/location, dressing application, post-procedure patient and family instructions, and any communication with a referring physician.

17260 17286 (destruction of malignant skin lesion): The destruction procedure, plus review of pertinent medical records data, discussion of the treatment options and risks, obtaining informed consent, tray prep, lesion inspection and palpated, exam for size/depth/location/functional risks, dressing application, instructions, discussion of recurrence risks and the need for follow-up, and any communication with any referring physician.

11100 (biopsy of skin lesion): The biopsy procedure, plus pertinent history, indications, expected benefits, discussion of the procedure and its risks, tray prep, selection of the optimal biopsy site, lesion inspection and palpation, patient instruction on care and follow-up, and communication with any referring physician.
 
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