Wiki Coding edge August 2012

[wrightju1]

In the article on Global Period E/M Modifier an example is given for use of the 25 modifier that has me confused.

It gives and example of a patient presenting with left eye pain after doing some household repairs. The physician performs an exam, finds a wood splinter and removes it. He documents and bills 99212-25 and 65220-LT, with 930.0. I am having a hard time seeing this as proper use of the 25 modifier.

Can someone shed some light on the perspective on this? And if this article has already been discussed please direct me to that conversation.

 

[donnalynn]

In the article on Global Period E/M Modifier an example is given for use of the 25 modifier that has me confused.

It gives and example of a patient presenting with left eye pain after doing some household repairs. The physician performs an exam, finds a wood splinter and removes it. He documents and bills 99212-25 and 65220-LT, with 930.0. I am having a hard time seeing this as proper use of the 25 modifier.

Can someone shed some light on the perspective on this? And if this article has already been discussed please direct me to that conversation.

I hope this sheds some light for you:

Definition of modifier 25:
Significant, separately identifiable evaluation and management (E/M) service by the same physician on the day of a procedure.

Appropriate Usage:

Modifier 25 indicates that on the day of a procedure, the patient's condition required a significant, separately identifiable E/M service, above and beyond the usual pre and post-operative care associated with the procedure or service performed.
Use Modifier 25 with the appropriate level of E/M service.
The procedure performed has a global period listed on the Medicare Fee Schedule Relative Value File.
An E/M service may occur on the same day as a procedure and within the post-operative period of a previous procedure. Medicare allows payment when the documentation supports the 25 modifier and the 24 modifier (unrelated E/M during a post-operative period.)
Use Modifier 25 in the rare circumstance of an E/M service the day before a major surgery that is not the decision for surgery and represents a significant, separately identifiable service.

 

[wrightju1]

Right, I understand the definition for the 25 modifier. That's why I have a hard time with the use of it in this example. How is the E/M seperate from the procedure of removing the object from the eye?

 

[donnalynn]

Right, I understand the definition for the 25 modifier. That's why I have a hard time with the use of it in this example. How is the E/M seperate from the procedure of removing the object from the eye?

Do you have a history and physical documented by the physician? If so then he can bill a separate E/M level along with the procedure, adding the 25 modifier to the level. If the only documentation is the procedure then no, you cannot bill for the E/M level and it is not separate.

 

[wrightju1]

Yes, the example given in the Coding edge gave the details of a documented problem focused history and exam and straightforward MDM. There is no question about the proper documentation for the 99212.

My understanding is that for a minor procedure (65220 removal of foreign body, external eye) the e/m work that went into the decision to perform the procedure is part of the procedure. A modifier is an "exception to the rule". What makes this a "seperately identifiable evaluation and management service".

 

[Lynda Wetter]

I agree and have a hard time justifying the use of 25 on most claims.
There was no seperate evaluation done, the only evaluation was of the foreign body.
NCCI edits cleary say the decision to perform the surgery is included in the minor procedure. So I see that as the exam to make that decision is included in the procedure.

 

[OCD_coder]

Please understand that the article was from 2012. Medicare and many carriers have since tightened their rules concerning use of the modifier 25 and that example would now have difficulty supporting a separate E&M service. Simply doing a history and exam is insufficient to support a significant E&M from the procedure. CoderGirl is correct that simply making the decision to perform he procedure is insufficient per MCR guidelines.

Use examples from your local Medicare MAC to guide you as they will be more current and accurate with the current guidelines. I have included Palmetto's guidelines with examples that are more current for assistance here.

http://www.palmettogba.com/palmetto/webtool.nsf/vtool/mod25