A question regarding the 25 modifier

LanaW

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I was told yesterday by a fellow CPC that I can't use a 25 modifier on an E&M code if the other CPT being billed is NOT in the surgery category codes. In other words if the "other" CPT code is an ultrasound, spirometry, etc. I shoud NOT use the 25 modifier - even when the office note supports it. (that is the only time I am using it) I have been using it on my E&M codes when we do ultrasounds because the patient presents for one problem which leads to another and the secondary reason is why the U/S is performed. These ARE getting paid. Now I am confused!! Thanks!
 
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Lisa Bledsoe

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I think a lot of time it depends on the payer. I do not use modifier -25 on an E/M if an ultrasound is performed, but I do if a procedure from the surgery or medicine section is done. The key term here is "procedure". Just another CPC's perspective...:)
 

LanaW

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OK, you (Guru) stated you use a 25 modifier if a "procedure" is done from the medicine section which are the codes beginning with 9s. I was told this is also inappropriate. I disagree with this but this particular person is extremely insistant that she is correct. Any thoughts?
 
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scorrado

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The definition of -25 modifer states "same day of the procedure or other service" so it is not specific to procedure. In my particular specialties I do not have to use -25 too often but when I do it is with procedures but just by looking at the definition I would use it for other things also if it applied.
 

Treetoad

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I agree with Guru. Our BC/BS carrier requires modifier 25 on E&M services when other services are provided, whether procedures or labwork.

~L
 
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Hi,

Okay...my 2 cents worth....

Modifier -25 is appropriate when billing for a "separately identifiable e/m by the same physician on the same day of the procedure or Other Service".

The medicine section includes cardio cath's, cardiography codes, etc. which would fall under the "other service" category.

Below is a link that distinctly shows that modifer 25 (and 57, for that matter) are appropriate to use on e/m's when done with heart procedures found in the medicine section.

http://www.cardiacinterventionstoday.com/PDFarticles/0607/CIT0607_02.php

Further, a modifier 25 can be used when billed with 2 e/m services - a preventive and a "diagnostic" e/m. These aren't codes from the "surgery section", as your co-worker states.

I don't agree with her limited/restricted use of a modifier 25. Hopefully, I've given some info you can use to get her over to your way of thinking! Good Luck!!
 

Lisa Bledsoe

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CPT clearly states in the definition of modifier -25 in Appendix A that it is reported with an E/M code on the same day as a procedure or other service. I would point this out to your fellow CPC...along with all the other posts in this thread. As long as the documentation for the E/M supports that it (the E/M) is a significant, separately identifiable E/M from the procedure (i.e. any code from the surgery or medicine section...and perhaps even the radiology or lab sections as required by the carriers) it is appropriate to use modifier -25.
Lisa Curtis, CPC-I, E/M
 

debi7478

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Mod 25

I am having the same issue Many Many insurances are not paying for ANY additional visits or procedures if done on the same day whether or not a modifier 25 is attached.

If any of you are having the same issues can you let me know. I am really not sure what to relay to my superiors on this as we try to to accomodate the pt when they are in the office and take care of everything. sometimes the visit will support and additional visit code sometimes not, HELP need more clarification.


Debi
 

MsMaddy

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mod 25

FYI

Modifier 25 is only used on office levels E&M service with other procedure on the same day. If no E&M was done only a procedure, then you can not use
modifier 25. I hope this helped.

msmaddy
 
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Hi,

With regards to insurance denials, I think it depends on the "claims scrubber" they use & specific payors. I have been told that McKesson's product has edits built in that automatically issue a denial when a modifier (-25) is flagged with a same DOS procedure. I also am aware of a local HMO that will not reimburse physicians on E/M procedures with a (-25). I have tried numerous levels of appeals w/ chart notes clearly showing that services were "separately identifiable" to no avail. Apparently, this caveat is written into the contract. It really is frustrating.
 
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