Wiki 25 modifier - only code the E&M

[nscoder]

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.

 

[ajgibson]

Hello,

recently payers have denied prevents and well child exams for not having the 25 on claims where injections were done during the same encounter. In your examples, I would bill the E/M, the Rapid Strep, AND the injection & drug. The -25 modifier would go on the E/M because of the injection.

Now, if there was NO E/M, just a nurse visit for an injection, only bill the injection.

Hope this helps!

Amanda Jent, CPC-A
Coding Analyst
Memorial Healthcare
MMA Department
ajent@memorialhealthcare.org

 

[rthames052006]

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.

In regards to the e/m with immunizations that is a newCCI edit that became effective 1-1-13. It seems as though other carriers are just picking up on this.

I know in my area Capital Blue Cross just started following this effective 3-1-13.

So when a patient comes in for an office visit or preventive visit and immunizations are administered 90460-90461, 90472-90474 you'll need to add modifier 25 to the e/min order to get the e/m paid.

Check CMS website for more details.

 

[Lynda Wetter]

Here's a statement for the Americam Academy of Pediatrics adressing the issue.
On January 1, 2013 the Centers for Medicare and Medicaid Services (CMS) released the latest version of the National Correct Coding Initiative (NCCI) edits. The NCCI edits are code edits published by both Medicaid and Medicare to support correct coding and claims adjudication. Included in the new Medicaid and Medicare edits were edits on all evaluation and management (E/M) services that disallow patient with immunization administration codes without the proper modifier. The modifier indicator for all these edits is a "1," meaning that with proper modifier placement, the edit can be overridden.

While the Academy is urgently working with National Correct Coding Solutions - the CMS contractor for NCCI edits - to have the edits suspended on all preventive medicine service codes (99381-99385 and 99391-99395) with all immunization administration codes (90460 and 90461, 90471-90474). It should be noted that the edits are currently locked in and will continue to be in effect for Medicaid, Medicare, and private payers that implement CMS coding policies until such time that AAP advocacy efforts are successful. Over the past several days, the AAP has been in telephone contact with the highest levels of the CMS contractor responsible for the NCCI edits and has delivered a formal letter demanding retraction of these edits.

Therefore, effective immediately and for all claims submitted after January 1, 2013, AAP urges its members to append modifier 25 to the preventive medicine service code (99381-99395) when it is reported in conjunction with any immunization administration service (90460-90461; 90471-90474).

A modifier 25 should also be appended to other non-preventive medicine E/M services (eg, 99201-99215) when reported in conjunction with immunization administration -- but only when the E/M service is significant and separately identifiable.

We understand this is an administrative burden for you and your staff. The AAP is working diligently to unlock this change and will forward additional information on this issue as it becomes available.