Wiki E/M after ECT- What validates modifier 25

[mc1030]

Hello Everyone,

I've been dealing with a lot of confusion about Unbundling E/M Post ECT procedures. I have claims that are denied because "the service is considered to be part of the procedure already billed" A lot of the times when I review the documentation to see if it supports modifier 25, it's seems more of monitoring than really a separate E/M.
Documentation will have notes stating how the patient is feeling post ECT, compliance with medication, and then the basic ROS along with the Dxs. There are times that the Dr will do ECT and then sees the pt an hour or 2 later. Other times, it will be done at 8am and then checks the patient late at night like 10 or 11pm.
Are there any examples that anyone can provide that would validate modifier 25? I understand that it has to be a change in the condition, a need for medication adjustment, or unrelated to the procedure but I never did a practice case study on this type of scenario to really grasp a good idea of how the documentation should look.

Any advice would be greatly appreciated. TIA

 

[TThivierge]

MC1030
Well unbundling notices are linked in the CPT manual especially under Eva MGnt codes. It will state do not code these CPT with these CPT on same date of service. Modifier 25 is done as added procedure with office visit to be supported of the dx code.
Examples
PT arrive for treatment of chronic conditions(ie E11, N18, I10), but pt. tells provider has severe ankle joint pain so Arth. CPT 20605 injection done, add injection meds, then add modifier 25 to EVal Mgnt CPT code 99213
Female pt. arrive due to pap but pt states has a cyst on foot which provider lances add modifier 25 to 99396 (est.pt. physical over 40 yrs old), and CPT 11300
Pt arrive in EMR with migraine and chest pain, doc orders chest xray and MR of brain, then add modifier 25 to EMR visit 99284.
However if pt scheduled in advance to have just a clinical procedure just code the clinical procedure NOT Eval Mgtn too.
I hope this data helps you
Have a good day!
Lady T

 

[sls314]

Hello Everyone,

I've been dealing with a lot of confusion about Unbundling E/M Post ECT procedures. I have claims that are denied because "the service is considered to be part of the procedure already billed" A lot of the times when I review the documentation to see if it supports modifier 25, it's seems more of monitoring than really a separate E/M.
Documentation will have notes stating how the patient is feeling post ECT, compliance with medication, and then the basic ROS along with the Dxs. There are times that the Dr will do ECT and then sees the pt an hour or 2 later. Other times, it will be done at 8am and then checks the patient late at night like 10 or 11pm.
Are there any examples that anyone can provide that would validate modifier 25? I understand that it has to be a change in the condition, a need for medication adjustment, or unrelated to the procedure but I never did a practice case study on this type of scenario to really grasp a good idea of how the documentation should look.

Any advice would be greatly appreciated. TIA

I once heard someone explain it in a way that really helped it click for me:

If you took a Sharpie and blacked out everything in the note related to the ECT, would what’s left still be significant enough to justify its own E/M charge?

That mental image helps me quickly gauge whether the E/M service stands on its own as “significant and separately identifiable" and supported a Modifier 25.