Wiki E/M Modifier 25

[murph542]

Hi, I’m auditing BH for Virginia Medicaid. I’m reviewing BH providers who bill for med management as 99214/99215 and add-on codes for psychotherapy as 90936/90837. My question is on whether modifier 25 is needed on the E/M codes when billing the psychotherapy add-ons? One provider is using it for every claim that has both codes, but the majority of providers have not been using it. I thought you didn’t need modifier 25 since the 90836/90837 codes are add-on codes. Can anyone provide some insight either specific to Medicare or Virginia Medicaid? And if possible, links to official guidelines I can use for citations in my reports. Thank you!

 

[Pam Warren]

Add on codes do not ever (in my 35+ years' experience) require a modifier.

 

[jkyles]

As always, the full descriptor for the modifier (located in Appendix A of the CPT manual) answers a lot of questions about the use of the modifier. And there's an article from the AMA https://www.ama-assn.org/practice-management/cpt/setting-record-straight-proper-use-modifier-25

 

[Jennifer.White@atg.in.gov]

Agreed on the modifier 25 issue - I run into this often where a provider just blanket bills all of their E/Ms with the 25 modifier. On the add-on codes, what sort of documentation are you seeing to show that it's separate and distinct from the E/M? I tend to see very little to support a full E/M when I run into these.

 

[jkyles]

Agreed on the modifier 25 issue - I run into this often where a provider just blanket bills all of their E/Ms with the 25 modifier.

Yikes, that sort of billing pattern could trigger an audit.

On the add-on codes, what sort of documentation are you seeing to show that it's separate and distinct from the E/M? I tend to see very little to support a full E/M when I run into these.

I'm not sure I understand this question. An add-on code is always performed with a primary service. Is the issue that the E/M documentation isn't there?

 

[Jennifer.White@atg.in.gov]

Yikes, that sort of billing pattern could trigger an audit.


I'm not sure I understand this question. An add-on code is always performed with a primary service. Is the issue that the E/M documentation isn't there?

Yes, it did indeed trigger an audit.

On the documentation, there was enough evidence to support the psychotherapy (counseling), but the E/M was documented as just very basic - they took vitals and confirmed they were taking their meds. To me, that doesn't read as enough documentation so I was wondering what sort of things you see as documenting a separate and distinct service for the E/M portion.

 

[murph542]

As always, the full descriptor for the modifier (located in Appendix A of the CPT manual) answers a lot of questions about the use of the modifier. And there's an article from the AMA https://www.ama-assn.org/practice-management/cpt/setting-record-straight-proper-use-modifier-25

Thank you for the link to the article!

 

[murph542]

Thank you everyone for your help! I was overthinking things and not actually thinking about what I was reading.