Wiki -25 Modifier on all E/M procedures

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abs1821

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Having an in office debate on this and wanted to see if anyone had answers.

I was under the impression that you can set your code sets to include modifiers even if the modifier isn't needed (example...you perform a 99203 but NOT 98941 but the 99203 still bills with 25 modifier). Our business manager thinks you're not suppose to have the modifier if you don't need it for that claim.

Can anyone shed some light on this?

Thanks in advance!
 
Modifier 25 is used to break an NCCI edit on a CPT code with a global period of 0-10 days. If it is not appropriate to use it you should not have it on the claim. It would be the same as missuse of modifier 59 on a claim.
 
By adding a modifier you are telling the insurance that there is another "Separately Identifiable" procedure on that same DOS. IF you do not have that then that is misuse of the modifier and that could potenitally flag you for audit.
I hope you are not doing this to Medicare as that is fraud in a huge way.
 
If you are just billing an exam (99203) with no adjustment (98941), you do not need the modifier. The only reason you would use the modifier is to break the NCCI edit.
 
We haven't done it here but another practice I worked at they did it as a standard BUT they always billed adjustments the same day as an exam, here they do not the exam is on a separate day and they are adjusted at the ROF.
 
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