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deb.steelers2@gmail.com

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My question is this: The below appear to contradict each other, here's how, if I am adding -25 due to a service, E&M or procedure by another QHP then that service will NOT be on my claim. Under the tips your definition states you cannot use -25 if you are only billing one line item..... So if I have an E&M on the same day as a service by another QHP what modifier is appropriate? Ex: primary care E&M on the same day as an x-ray reading, or the pt sees multiple providers on the same day (previously we used -25 for the subsequent E&Ms but according to below we cannot do that and modifier 76/77 are not E&M appropriate).

Modifier 25: (Copied the descriptor) 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

Under Tips: Although the news that all procedures contain a minor related E/M service might surprise you, you probably know that modifier 25 submissions require a minimum of two codes. However, auditors tell the Insider that not all coders are aware of this, and that they occasionally see modifier 25 on claims when an E/M visit was the only service reported. Without an accompanying initial service or procedure, you can't have a significant, separately identifiable service, experts say. When submitting claims consisting solely of an E/M code, make sure you don't include modifier 25.
 
deb.steelers2@gmail.com said:
My question is this: The below appear to contradict each other, here's how, if I am adding -25 due to a service, E&M or procedure by another QHP then that service will NOT be on my claim. Under the tips your definition states you cannot use -25 if you are only billing one line item..... So if I have an E&M on the same day as a service by another QHP what modifier is appropriate? Ex: primary care E&M on the same day as an x-ray reading, or the pt sees multiple providers on the same day (previously we used -25 for the subsequent E&Ms but according to below we cannot do that and modifier 76/77 are not E&M appropriate).

Modifier 25: (Copied the descriptor) 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

Under Tips: Although the news that all procedures contain a minor related E/M service might surprise you, you probably know that modifier 25 submissions require a minimum of two codes. However, auditors tell the Insider that not all coders are aware of this, and that they occasionally see modifier 25 on claims when an E/M visit was the only service reported. Without an accompanying initial service or procedure, you can't have a significant, separately identifiable service, experts say. When submitting claims consisting solely of an E/M code, make sure you don't include modifier 25.
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Are all of the providers the same specialty and under the same tax ID?

I'm just trying to clarify why you think you might need a modifier if you're only billing for an E/M visit for that provider.
 
I think I understand what you are asking. You would append a 25 if two different providers under the SAME billing tax ID or group are seeing the same patient on the same date for two different problems. If not, your E/M are going to hit against each other even if on your claim it is only a single line. It also depends on how the payer you are billing processes or allows multiple E/M on the same date from the same group. You wouldn't append it if your patient was seen by a different provider/group/Tax ID, rendering because it's two different Tax IDs so your claim "should not" hit against that. If you work for a group that bills under the same Tax ID, and you know your patient saw Dr. PCP in that group and you are billing for Dr. Ortho (for example) later in the day, Dr. Ortho (or at least one of them) would need the 25. Or, let's say it was all a big ortho group and the patient saw Dr. Sports for one shoulder problem and then saw Dr. Spine for the lumbar all in the same day. Some payers don't allow 2 on the same day even if the specialties are different, you would have to check the payer. Office/outpatient and ED, IP admit, etc. on the same day may have different rules as well.

What the tip is saying is it makes no sense to see a modifier 25 on a single line item for a day when no other claims or line items are being submitted by the SAME provider/group/practice.
If I was billing a 99214-25 and nothing else was billed on the same date, by the same provider or group (same NPI, Tax ID, billing provider) the 25 is wrong.

https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/clm104c12.pdf see 30.6.7 B
 
Susan,
It would be both, some under the same TIN some under another. To further complicate matters, we are hospital based so the question has been raised, if the doctor is billing the E&M but the facility (HB side) bills for any shots, nebulizer use etc for is -25 appropriate?

Amy,
That helps a lot! I did post the above further clarification in response to Susan's question.

Deb
 
PB/HB are two different things so they shouldn't bump against each other. But, you would have to know what TIN is being used for the pro-fee submissions. Depending on your EHR there should be edits and checks set up to catch this and alert that a 25 may be required. That is, if the edits are set up correctly.
So, if you had a big group all using the same TIN, like the example above if the PCP sees the patient in the morning, and same patient goes to Dr. Specialist (neuro, ortho etc.) you will need a modifier on one of them provided the documentation supports and all the other requirements are met. And, the payer honors different subspecialties. There are other issues where you might have to roll it all up into one but it is scenario/payer dependent.

That "tip" you are quoting above is not taking into account big groups and the TIN issue where there could be multiple claims on the same date but each claim might only have a single line.
 
Along the same idea, if I am a facility billing an E/M and PT eval on the same DOS by 2 different providers (Physician and PT) and both services go out on the claim form, is a 25 appropriate on the E/M service? We are receiving denials if we don't add it, but the provider is not technically the same.
 
barrett said:
Along the same idea, if I am a facility billing an E/M and PT eval on the same DOS by 2 different providers (Physician and PT) and both services go out on the claim form, is a 25 appropriate on the E/M service? We are receiving denials if we don't add it, but the provider is not technically the same.
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Yes, sometimes you have to if it's the same TIN/group it depends on the contract setup, NPIs, and TINs a lot of times depending on how the practice is setup. I think a couple payers used to do this back when I worked on the ortho provider side and did ortho & PT. I think you have to just confirm all of that info and of course that it really was two separate services, etc.
 
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