Wiki E&M (with 25 mod), procedure, and RX written

[CoderinJax]

I have some records where normally the E&M would be denying as included in the procedure (Trigger points, etc), but the Physician is adding the 25 modifier, so it bypasses the Edits.
When I'm reviewing the records, they don't meet the criteria for the "25" as there nothing significant is noted. However, he writes the patient an RX and I was curious if anyone had anything on if this alone would constitute allowing the "25" in their opinion? Sometimes it's the same RX as the prior visit, sometimes it may be trying a new RX. The Physical Exam is extremely limited (1 body system, if any) and the majority is just a little bit of Past hx.

Anyone have any strong opinions on whether to allow a 25 modifier for an E&M that normally would deny, but because there's an RX written they'd allow it?

 

[Pathos]

What was the purpose of the visit? If the purpose was to treat the underlying condition with Trigger points and the provider throws in an Rx to treat the underlying problem, I would be hesitant to bill both E/M +25 and a procedure. Based on what you are describing, there is no significant, separately identifiable problem the provider is dealing with, and I would bill the procedure only.

If the Rx was for a different problem (for example HTN or cough), then you could probably do Modifier 25 if the other E/M components are there.

Hope that helps!

 

[CoderinJax]

Helpful!

That helps, thanks, Pathos!
Yes, the RX's are for the same pain that the patient is coming in for the injections for. The E&M's typically don't support the 25 modifier imo, because they barely stand on their own.
There is typically either no P/E (or only 1 area), and half the time there is no ROS, or if there is one, it's so vague and is me being generous "guessing" it was an ROS that took place, but it's not distinct by any stretch.
I'm wondering if I would lose the argument, though, since some may consider writing an RX high enough MDM to constitute the modifier being used, and I can't find anything written that shows either way.

 

[thomas7331]

If you're looking for something in writing, see the 'Surgery Guidelines' in the CPT book, at the beginning of the surgical codes section of the book, you'll find a CPT Surgical Package Definition. It defines all of the elements that are inclusive, which would cover E&M and a related prescription (see 'writing orders' below) as a part of the package and not separately billable as an E&M service. Hope this might help some.

In defining the specific services "included" in a given CPT surgical code, the following services related to the surgery when furnished by the physician or other qualified health care professional who performs the surgery are included in addition to the operation per se:
Evaluation and Management (E/M) service(s) subsequent to the decision for surgery on the day before and/or day of surgery (including history and physical)
Local infiltration, metacarpal/metatarsal/digital block or topical anesthesia
Immediate postoperative care, including dictating operative notes, talking with the family and other physicians or other qualified health care professionals
Writing orders
Evaluating the patient in the postanesthesia recovery area
Typical postoperative follow-up care

 

[CoderinJax]

Thank you!

Thomas, THANK YOU!
I feel much better after reading both of the responses I received back with what my original thought process was. I started to doubt myself, and wondering if I should be allowing it, but the records just don't support it.
Have a great week, guys!