Wiki 25 modifier

[umas86]

Hi all,

I need a clarification regarding billing the EM with 25 modifier along with minor procedure. I work for urology providers, they plan for a minor procedure like cystocopy in the initial visit. The f/u visit is marked as procedure visit but after the procedure description, he provides a template note like " NOTE: A separate office visit was done after the cystoscopy counseling patient on evaluation of LUTS withcystoscopy and urine culture and urinalysis and management options for LUTS, including behavioral modifications(e.g reduction of caffeine intake), medications (e.g. Myrbetriq), botox injection in the bladder, and PTNS."

Can this note be considered to bill for seperate EM CPT like 99213 or 99214 OR this qualifies only for a procedure visit and only procedure should be billed.

Please advise. Thank you in Advance

 

[kdlberg]

A good guideline for figuring out if you need -25 is "if I took away everything related to the procedure and the reason for the procedure, would I have enough left for an office visit?" In this case, no. The education all related to the cystoscopy and management of the condition that is being treated (the LUTS.) There isn't "separate and significant" work done related to another condition.

 

[umas86]

Thank you so much!

 

[jkyles]

Agree with kdlberg and would just add it helps to:

Remind the provider that payment for a procedure includes pre- and post-procedure work, such as post-procedure counseling.

Give them the full descriptor for modifier 25.

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.