Question Modifier 25 and 2021 E/M Guidelines

tg

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Jackson, NJ
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It seems easier to add the modifier 25/bill a visit together with a minor procedure now that there are no specific requirements for history and exam. For example, if a patient had fungal toenails debrided and also had medication prescribed for the fungal toenails. In the past, we couldn't bill a visit and modifier 25 since there was no separate exam and history. Now if it is only based on medical decision making, why not?

Thank you for your help.
 

Deborah Marsh

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Hi - The office and outpatient E/M codes still include a medically appropriate history and exam, and procedures still include the related pre/post-op services (depending on what the global period includes). So proceeding with caution when deciding whether to use mod 25 seems like a good idea to make sure the documentation supports a separate E/M code (and if so which one) once the services paid under another code are excluded.
 

kimberlywatson

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Brentwood, TN
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Looking for guidance for documentation to support using 25 modifier,especially with injections (new and est patients). With new documentation guidelines, if no other problems or issues are addressed, I am having difficulty supporting the 25.
As Deborah stated above, the provider still needs to document a history and exam if medically necessary. If no other problems or issues are addressed and the issue has not changed, then a separately billed visit along with the procedure is not supported, regardless of which guidelines you refer to. Keep in mind that part of the description for "significant and separately identifiable" is "beyond the usual preoperative and postoperative care associated with the procedure that was performed". So that being said, it's not only when the provider is addressing a different issue that an E/M can be billed. This is why, if the patient is brand new or if this is a new issue, an E/M with modifier 25 is often warranted because the provider is doing an evaluation of the patient's history, examining the issue, and determining what treatment is necessary.

Hope that helps!
 

TWinsor

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Columbus, OH
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Looking for guidance for documentation to support using 25 modifier,especially with injections (new and est patients). With new documentation guidelines, if no other problems or issues are addressed, I am having difficulty supporting the 25.
 
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