mod 25

libraden

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If a pt comes in to have destruction of benign skin lesion and the doctor uses 17110 and then codes a 99212 with a 25, and they both have the same dx as 078.9, is this considered fruad. The doctors that i code for tend to do this alot with e/m and procedure codes. I look at 25 as being seperatly identifiable using the same dx and the the destruction for the lesion being the reason the pt came in, in the first place, how can we also charge for a e/m with a 25.
 
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skeeley

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I am definitely not a pro, but we were told if the patient was scheduled to come in for the procedure that an E/M could not be charged unless a seperate "oh by the way" came up. If they are using the same diagnosis for both the E/M and the procedure I do not see how that could be justified.
 

LindaEV

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it is not fraud to use a 25 on an office visit, and it have the same diagnosis as the procedure. What is fraud, is using the 25 just to get paid, when you know the office visit shouldn't be billed.

You will have times when all you should bill is the procedure, and times when the visit is acceptable. Per Medicare, the visit is always inclusive of a minof procedure.

You should Google "global surgical package" and share the documentation with the physicians.

If the patient is scheduled for a procedure, then what the doc is doing is just normal post-op work, and it's not seperately billable.
 

mitchellde

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If you look in the CPT book under appendix A for the definition of the 25 modifier it will state "as such separate diagnosis are not required for usage of the 25 modifer"
 

libraden

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So if the pt calls and makes an appt to see the doctor because they have warts on the bottom of the foot, and during the appt the dr decideds to inject them, would it be apporiate to bill the 99212 sense they just came in and then the procedure developed from that, but if they came in specifically knowing that the appt was for an injection for the warts would you not bill the 99212 then?
 

LindaEV

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Per Medicare "The initial evaluation is always included in the allowance for a minor surgical procedure"

https://www.cms.gov/manuals/downloads/clm104c12.pdf
See section 40.1

There is no yes or no answer to your question, because it would depend o the documentation and what exactly was done. Generally, I would not think a 99212 would be sepearetly billable. That is what the patient came in expecting and the doc took a peek and said, yep, let's treat them. That amount of work would be inclusive of the procedure code.
 
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