Wiki Can 25 modifier be appended to E/M New Patients CPT codes?

[Tracylynn527]

I work with a pain management clinic, and previously my physicians were seeing new patients, and performing a procedure same day (i.e. LESI, CESI, MBB etc). They would append mod 25 to the New Patient CPT code and then bill that along with the procedure code. We have recently been told that this cannot be done, and that modifier 25 cannot be used as it will not get reimbursed. I have learned in the AAPC course, that modifier 25 can be used for significant, separately identifiable services, which they do perform, so I am just very confused. Hoping someone has some answers as to if 25 just cannot be billed with a new patient E/M code, or if this is absolutely never payable??

 

[Arnkpc]

Modifier 25 can be used with new patient E&Ms.

Like you said, it can be used if the E&M is significant and separately identifiable. If you submit a claim with an E&M and a procedure without a modifier, the insurance company can say that the E&M is include with the payment for the procedure. The way I like to explain it to people is that the payment for the procedure includes coming and speaking with a doctor about related stuff. So by adding Modifier 25 you are saying that besides the procedure and related doctor engagement, discussion etc. The doctor also had a separate and identifiable evaluated and management encounter.

Keep in mind though, the documentation needs to support that it was separate from the procedure. You should be able to get the doctor's notes and draw a circle around the documentation for the procedure, and then, not using anything in that circle, you should still have all the documentation needed for what ever additional E&M code you are appending with Modifier 25.