Mod.25 explained, correctly?

[kiku3@ptd.net]

I am going to repost a statement someone posted back in August because I believe a correct answer as to whether or not this is a valid statement would help a lot of people understand this Modifier:

"If the service (CPT code) was DIAGNOSTIC (required for the physical exam and or MDM of the CC), then NO modifier 25 is needd on the E/M code. If the service (CPT code) was actually TREATING the condition diagnosed, then modifier 25 is neeed on the E/M code"

here is my example of a recent claim from a doctor: Doc. billed a 99213,25 dx of 38870 (otalgia unspecified) with a 92567 (tympanometry, impedance testing). I do not believe that there should be a modifier 25 used. Opinions, please.

 

[jgf-CPC]

Modifier -25, Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service:

This modifier must be appended with an E/M service. This is the modifier you will need to use with the evaluation and management service done on the same day with other procedure done by the same physician. It has to be above and beyond the usual preoperative and postoperative encounter with the procedure. In fact, by using this modifier, it doesn't have to have a different diagnosis reported. The most important thing is that, the E/M level should meet its key components or if it is selected based on time spent with the patient (counseling and coordination of care). You have to be careful in using this modifier. It must meet medical necessity. As you know, there are procedures that already includes all other coordination of care and management.

Looking at this description of the 25 then I feel it still needs the modifier.

 

[lisigirl]

If you bill for a procedure on the same day as an E/M service, you must append modifier -25 to the E/M or the two services will bundle. However, you can only bill for the E/M if the visit was for something significant and separate from the procedure.

In the example you gave, if the patient came in to see the physician for an earache and during the course of the visit, the physician decided to do tympanometry as part of the work-up, I would bill for both services with the -25 addended to the E/M.

If the patient came in specifically for the tympanometry and prior to doing the test the physician performed an E/M, I would not bill for the E/M at all.

Does this make sense?

Lisi, CPC
eharkler@nmh.org