Wiki 25 Modifier Evaluation and Management

[bkb1229]

I have been coding Podiatry for many years and Medicare has always paid the New Patient E&M service separately without appending the 25 modifier. It was my understanding that for a new patient a separate evaluation service is needed to determine the type of treatment (procedure) needed. Recently, Medicare has recouped amounts paid in 2011 for New Patient E&M codes that were billed in addition to an office procedure at the advice of a RAC. When I called, I was advised to submit a reopening form appending the 25 modifier to the original procedure code. Most of these evaluation services are for the same complaint and diagnosis. A full exam in addition to the procedure was needed because the patient was new to practice. Should the RACs be recouping this money? Should I advise my Provider to append the 25 to all NP OV codes billed in conjunction of an office procedure even if it is the same complaint and diagnosis?

Example: Complaint is wound. Full exam performed.
99203
11042
Diag= 707.15

 

[taracpc]

Yes you need to have the 25 modifier on the E/M service every time the E/M is done with another service even on a new patient even if they diagnosis is the same. This is showing the insurance that you did both services. There are services that specialist can do without doing a E/M visit. Usually after the first visit they want to make sure that if you use the 25 it definably separate for E/M and the procedure.