Wiki 25 modifier w/ov, new pt.

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You can use a mod 25 with a new patient consult visit as long as the dictation in your visit covers you. I think they are just worried about the misuse of that particular modifier. It will be ok, ESP on the pateints first visit.
 
Professional Coder

Per NHIC's Modifier Billing Guide dated 10/2008; the 25 modifier should NOT be submitted with E/M codes that are explicitly for new patients only (92002, 92004, 99201-99205, 99281-99285, 99321-99323 and 99341-99345)
 
modifier 25

In my modifier book "Coding with Modifiers" third edition concerning modifier 25, some carriers do not want a modifier, but:
CMS guidelines (page 64):
The CMS recognizes the use of modifier 25 with E/M services within the range of CPT codes 99201-99499, 92002-92014, and Healthcare Common Procedure Coding System (HCPCS) level II codes G0101-G0175.
 
There is nothing in CPT or in the Medicare claims processing manuals that would indicate Modifier 25 should not be used with new patient services.

That said, SOME Medicare contractors have stated that Modifier 25 is not necessary when submitting claims involving new patient visits to them, but this is a MEDICARE CONTRACTOR-SPECIFIC claims processing issue. We must recognize that there are variations in how each Medicare contractor processes claims.

It's possible that one or more of you out there may have YOUR Medicare contractor telling you it is not needed when submitting claims TO THEM, but that doesn't mean that it is a universal rule among all insurers, or even all Medicare contractors.

Seth Canterbury, CPC, ACS-EM
 
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Hi, I am new to the forum but I would like some clarification on the 25 modifier. I generally do the insurance follow up with the cardiology group I work for but also do coding; recently we have been discussing the use of 25 modifier when billing an ov w/echo exams. I believe it is not necessary because there is no issue of bundling. Can someone please clarify this for me?

Thanks
New and Confused
 
Our new patient visits are being paid with/ without -25. I also read somewhere's that new patient do not require -25.


http://www.medicarenhic.com/providers/pubs/Modifiers%20Guide.pdf


Page 24

Billing Tips:
No supporting documentation is required with the claim when this modifier is submitted.
However, the patient's medical records must contain information to support the use of modifier -25 and be available upon request. The following are the exceptions:

o This modifier should not be submitted with E/M codes that are explicitly for new patients only: 92002, 92004, 99201-99205, 99281-99285, 99321-99323, and 99341- 99345. These services are not considered part of the global surgical policy.

o Use modifier -25 on initial hospital visit (99221-99223), an initial inpatient
consultation (99251-99255) and a hospital discharge service (99238 and 99239) ,when billed for the same date as an inpatient dialysis service.
 
lkozak30 said:
Per NHIC's Modifier Billing Guide dated 10/2008; the 25 modifier should NOT be submitted with E/M codes that are explicitly for new patients only (92002, 92004, 99201-99205, 99281-99285, 99321-99323 and 99341-99345)
Click to expand...

I have the same article. I added the link for anyone who wants to read it themselves.
 
I wholeheartedly agree with Seth. Medicare came out with the statment about mod 25 and new patients years ago. My own carrier has statements about this 10+ years ago. Since then, CMS does not include this verbiage in the regs. Chapter 12...nothing. MedLearn bulletins...nothing. You will find some independant Medicare contractors that may submit to this old mentality but CMS as a whole, no. My own carrier, who once heeded to this way of thinking, now denies claims without modifier 25. CMS keeps evolving and so will their regs.
 
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25 modifier w/ov, new pt

Hi Willingham, I saw your response and wanted to let you know that I attended an audio conference here at my job and it was in regards to Modifiers and it was done by Medicare. They did state that modifier 25 should not be submitted on an E&M code for a new patient. All of us in the conference were shocked because we had never heard of this before. If you go to the Palmetto GBA website under Ohio Part B Carriers then under modifier look up you will find information on all modifiers. I copied and pasted from there website about modifier 25:

This modifier should not be submitted with E/M codes that are explicitly for new patients only: CPT codes 92002, 92004, 99201-99205, 99281-99285, and 99341-99345. These codes are "new patient" codes and are automatically excluded from the global surgery package, meaning that they are reimbursed separately from surgical procedures. No modifier is required in order for these codes to be separately reimbursed.
 
OV with -25 modifier

Hi ,

We recieve payment for the OV (In case of Established pts )Visit with -25 modifier the level of Visit should be more than 99211 .ie 99212 - 99215. I hope it applies similar to the New pts too .. Certain cases the Cerumen impaction would be only reason for the encounter ,then it is not appropriate to bill both the removal of cerumen and OV code .

In case of Established pts :
Most of the Family care Physician provides , just an B12 injection or any vaccination and they bill for both the Visit and admin . Medicare denies the same and pays only for the Admin code . Usually the admin code is inclusive in 99211 .

It is the Coders responsibility to make aware of the Physician office to ensure that , they are aware of this rule .

As said by others it is appropriate to use -25 to OV when the level of visit is more than the first level , if there is distingiushable service rendered by the provider and the reason of the visit should be clearly understood and there is correct E/M level is choosen .Dont link the primary dx as same for both the OV and the other service rendered , this may also provoke necessity for denial .

Note : refer the clinical Example section in Appendix C in CPT book for the CPT codes .

Regards,
Kamala CPC:)
 
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About 96372 adn 99211

Dear Kamala,

Thank you for sending the reply. I unmderstood about modifier 25, but regardomg 99211 with adminitstration of injection either Depo or vaccination or B12 ext; for administration they pay for 96372 adn also for 99211.

I am working in private billing company who are working on the defaulte claims like above and insurance paid too. I certainly couldnt understand the correct rules and regulations of these insurances, they change for their conveniances.

Thanks any way

B Alloju

In case of Established pts :
Most of the Family care Physician provides , just an B12 injection or any vaccination and they bill for both the Visit and admin . Medicare denies the same and pays only for the Admin code . Usually the admin code is inclusive in 99211 .
 
Then let me ask you this...if a new pt comes in and can barely walk do to a fall. The pt's ankle is swollen, black & blue, and is experiencing a lot of pain. How can the provider assess the problem without an x-ray? You would need to add a -25 with the new pt o/v because the x-ray is being done the same day and to be interrupted by the same provider?
 
Hospital Consults w/heart cath

When a patient comes in to the hospital with chest pain, our Cardiologist is asked to see the patient and determines the patient needs to have a heart cath on that same day, to me, that is a reason to use the 25. Anybody else deal with this issue?

Thanks,
Debbie
Cardiology
KCMO
 
dja214 said:
Then let me ask you this...if a new pt comes in and can barely walk do to a fall. The pt's ankle is swollen, black & blue, and is experiencing a lot of pain. How can the provider assess the problem without an x-ray? You would need to add a -25 with the new pt o/v because the x-ray is being done the same day and to be interrupted by the same provider?
Click to expand...

if you are talking about just an OV and an X-ray, no modifiier is needed on the office visit. The x-ray is diagnostic and not consider a procedure per say.
 
You should not have to use a modifier on E/M when drawing labs. These are consider diagnostic. Not a procedure to something else done.
 
modifier 25

Thanks, can you find an official site regarding that? My manager/co-worker doesn't agree but I've not use that modifier when also drawing labs even with a Clea based office but for the life of me don't remember where that came from!!!
 
Modifier 25

Significant, Separately Identifiable Evaluation and Management Service by the Same Physician on the Same Day of the Procedure or Other Service: It may be necessary to indicate that on the day a procedure or service identified by a CPT code was performed, the patient's condition required a significant, separately identifiable E/M service above and beyond the other service provided or beyond the usual preoperative and postoperative care associated with the procedure that was performed. A significant, separately identifiable E/M service is defined or substantiated by documentation that satisfies the relevant criteria for the respective E/M service to be reported (see Evaluation and Management Services Guidelines for instructions on determining level of E/M service). The E/M service may be prompted by the symptom or condition for which the procedure and/or service was provided. As such, different diagnoses are not required for reporting of the E/M services on the same date. This circumstance may be reported by adding modifier 25 to the appropriate level of E/M service. Note: This modifier is not used to report an E/M service that resulted in a decision to perform surgery. See modifier 57. For significant, separately identifiable non-E/M services, see modifier 59. (01/01/2008).

If the claim meets all the above criteria,then it is valid
 
Whether or not you need the -25 for a new patient may vary by payer, but it would not be incorrect to expect to be paid for BOTH a new patient E&M and a procedure done on the same day, like an I&D. Check your payer rules to determine if the -25 is needed. If the provider had to take some history, determine med allergies and past health issues as part of the evaluation for the condition requiring the procedure, then clearly and E&M service was performed and should be appropriately coded and submitted for reimbursement.
 
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