Wiki Mod. 25

[Sarah Ann]

I know we can add data points in the E/M for things that were considered- but if a patient comes in for a laceration the provider repairs the lac.
- in the MDM- "patient doesn't think it hit bone, declines x-ray(assuming the provider asked the patient here) Does this in itself justify a separate E/M with a modifier 25 in addition to the repair?

 

[podcoder70]

If a patient comes in with a new complaint and an evaluation is performed and it is decided that a procedure needs to be porformed, you can code the appropriate level of E&M with 25 modifier AND the appropriate procedure code.

 

[jkyles]

I know we can add data points in the E/M for things that were considered- but if a patient comes in for a laceration the provider repairs the lac.
- in the MDM- "patient doesn't think it hit bone, declines x-ray(assuming the provider asked the patient here) Does this in itself justify a separate E/M with a modifier 25 in addition to the repair?

Hi there, it does not justify a separate charge for an E/M visit. Remember the full descriptor for the modifier (emphasis added):

Significant, Separately Identifiable Evaluation and Management Service by the Same Physician or Other Qualified Health Care Professional on the Same Day of the Procedure or Other Service: It may be necessary to indicate that on the day a procedure or service identified by a CPT code was performed, the patient's condition required a significant, separately identifiable E/M service above and beyond the other service provided or be beyond the usual preoperative and postoperative care associated with the procedure that was performed. A significant, separately identifiable E/M service is defined or substantiated by documentation that satisfies the relevant criteria for the respective E/M service to be reported (see Evaluation and Management Services Guidelines for instructions on determining level of E/M service). The E/M service may be prompted by the symptom or condition for which the procedure and/or service was provided. As such, different diagnoses are not required for reporting of the E/M services on the same date. This circumstance may be reported by adding modifier 25 to the appropriate level of E/M service. Note: This modifier is not used to report an E/M service that resulted in a decision to perform major surgery. See modifier 57. For significant, separately identifiable non-E/M services, see modifier 59.