-25
Guidance and Outreach
Guidance to providers regarding the use of modifier 25 is available
through a variety of sources, such as newsletters, bulletins, and letters
from contractors and the Centers for Medicare & Medicaid Services
(CMS). However, the governing source for determining appropriate
payment is CMS's “Internet-Only Manual.”9 Chapter 12, section 40.2 of
the manual states:
Modifier 25 is used to facilitate billing of evaluation and
management services on the day of a procedure for which separate
payment may be made. It is used to report a significant,
separately identifiable evaluation and management service
performed by the same physician on the day of a procedure. The
physician may need to indicate that on the day a procedure or
service that is identified with a [Current Procedural Terminology]
code was performed, the patient's condition required a significant,
separately identifiable evaluation and management service above
and beyond the usual preoperative and postoperative care
associated with the procedure or service that was performed.
In addition, CMS allows providers to use the Current Procedural
Terminology (CPT) Manual, published by the American Medical
Association, as a source of information regarding the use of modifier 25.
The CPT Manual contains detailed descriptions of the procedure codes
http://oig.hhs.gov/oei/reports/oei-07-03-00470.pdf
I guess it doesn't matter if it's a new or established patient as long as a significant, separately identifiable evaluation and management service above
and beyond the usual preoperative and postoperative care
associated with the procedure or service that was performed.
thanks,
adonis
Originally Posted by Willingham
Can someone share with me if you are aware, whether or not the 25 modifier is acceptable with a new office visit? I read early part of the year that the
OIG had audited and cited a high error rate when using this modifier with an ov for a new pt. because the new-pt visit is by definition a stand-alone billiable visit. Any thoughts of this???? thanks. Also when coding this ov with a procedure the CCI edits tells you, you need to append the 25 to pass the edit. ????????????????????