Wiki Billing Modifier "25" with E&M & 94010

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Merilee Silverstein

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I am being challenged by my physicians and insurance payers in regards to our coding E&M services with modifier "25" AND 94010. According to the definition for modifier "25"
"... the patient's condition required a significant, separately identifiable E&M service above and beyond the other service provided..." "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 the E&M services on the same date."
Since my physicians are allergists/immunologists, they frequently perform spirometry tests for initial & established patients alike & there may not be a significant, separately identifiable condition to validate code 94010 and E&M+25. So, is it appropriate for us to code E&M+25 and 94010 for 1 ICD9/ICD10 code only? Dazed and Confused
 
94010 & e/m

Hi,

Did you resolve this issue? We bill for a Pulmonary practice and are seeing a lot of denials when we will an E/M with -25 along with a 94010. On some claims we are billing with different dx codes, but the claims are still being denied.

Thanks!
 
Hi,
There is no chanches to pay E/M+25,spirometry without significant with the procedure and E/M.If the ICD codes doesnt support to evaluate the significance to the procedure and E/M, The only way we should judge the document weather its significant or not,otherwise it will deny from the payer.

I hope this will help so,

Thanks,
Sathyaraj B.Pharm,CPC,CEMC
Medical auditor BCBS
 
Hello,
I work for an Allergist/Immunologist as well and we always bill an E&M with a modifier -25 when code 94010 has been done. When I'm coding this, I always make sure that the diagnosis code linked to code 94010 is appropriate (ex: 493.00) We don't have issues with them getting denied.
 
Same problem here. We are a Ped Pulmonary Group. Always utilize the -25 for E/M, but about 60% of the time we have to file an appeal to get paid due to NCCI edits. So frustrating!
 
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