Modifer 25 with multiple procedures


Portland, OR
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Patient came in for E/M to discuss treatment options for numerous skin cancers Non-melanoma Skin Cancers (NMSCs) several biopsy proven. Came to office to discuss treatment options. Physician removed several via C & D as well as biopsy a lesion on jaw and treated some AKs.

A former patient not seen since 2007 here with h/o multiple NMSCs, most recently BCC, nodular and ulcerated and type L anterior cheek, BCC nodular type L Posterior cheek, SCCIS inferior cheek, superficial SCC L neck and SCCIS L anterior shoulder, all biopsy proven by Dr. XXXX at XYZ University Hospital on 6/21/16. Would like to discuss pathology and treatment options. Has not noted a lesion on R jaw.

No additional skin complaints
No constitutional complaints

Exam: Patient appears well developed, nourished, in no apparent distress and appears stated age, Examination: Scalp and body hair, head, neck, chest, abdomen, buttocks, back, R arm, L arm, R leg, L leg, nails, digits, eyelids, lips.

Physician C&D-ed 3 bx proven BCC on cheeks, a SCC on shoulder, a biopsy on R Jaw, Cryosurgery on AK x 3 on temple.
He also diagnosed Hx of NMSC and Lentigines and counseled to return to clinic if any change or look suspicious. Sun avoidance and sun-protection discussed and recommended.

Here is what physician wants to bill:
17003 x3 -XS

Since the CC and HPI were all about the bx proven lesions and pt wanted treatment plan and physician actually treated (C&D) during that session, can physician still charge E/M and use 25 based on this to support a separate E/M?? If so, can it support a 99203???

A second look and input appreciated.

Melissa D.


Yakima, WA
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I would either use XS or 59. The X modifiers are meant to replace 59 so I wouldn't use a combination of both on same claim. It also depends on whether the payer is accepting the X modifiers. I also wouldn't use the 76 modifier. Repeat procedure implies you did the exact same procedure on the same anatomy twice in one day. A nosebleed might be a good example of using 76. Patient comes in for epistaxis and the nose is cauterized and packed. Then the patient returns 4 hours later still bleeding through the packing and the procedure is repeated.

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Here's my two cents:
First thing, I've always been told never to use modifiers on add-on codes. If the modifier(s) is on the primary procedure, the add-on code will always apply the mods from the primary code as they are extensions, rather than separate pieces.

On the 17000-XS,17003 x 3 -XS, why are you billing 3 units for 17003? +17003 includes the 2nd to the 14th lesion, so with 3 units you'd have at least 28 or 29ish additional lesions, give or take.

Regarding the -59 on 17281 x 3; this is from CMS:
"Modifier 76 definition does not state that this is a repeat procedure in the exact same area. The
modifier 76 indicates that this is a repeat of the same procedure on the same date of service. A
procedure is identified by the CPT code description, absent of any modifiers. Therefore, if you
perform the same “procedure” in multiple locations, modifier 76 is appropriate... Modifier 59 is
not appropriately filed when it is used to indicate that a single procedure code was performed more than
once per day. In this instance, modifier 76 or an anatomical modifier is the appropriate modifier to indicate
that the same procedure code was repeated more than once per day"

So that reads to me as billing 17281 repeatedly for that date of service would not meet the definition of a 59, and that a 76 should be used (in the absence of an anatomical modifier)

Also -XS can't be used for the "Exact same procedure code reported more than once on the same day" so I'd drop the -XS from 17281 also.

There's a bunch more rules about -XS in general:
Inappropriate Usage
- Code pairs are not part of the NCCI procedure to procedure edits
- If another valid modifier exists to identify the separate services
- The NCCI code files show the modifier application as "0"
- Documentation does not support the services were provided on a separate organ/structure; For example, both procedures were performed on the liver during a single encounter
- Exact same procedure code performed twice on the same day
- Submitted with Modifier 59

So I'd check the other codes with -XS regarding edits if I was considering adding them.

As far as the 99203-25, based on the documentation you posted, I can't see any possible way that that visit could level up to 99203. For example, if he discusses Skin in the ROS, then it can't also be counted into the HPI as that would be "double dipping."
As far as the Exam goes, to me it reads that he examined the Skin and mentions some constitutional bits and pieces. So from my point of view, although he examined all these various sites, ultimately it's one organ system (Skin). If I were to code this, I count 1 organ system and 1 for the constitutional piece at best.

I can dig up the links for all this info if you need them, I just have the documentation saved rather than bookmarked.