Modifier 25 Doubt !!!!!!!!!!!!!!!!!


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A patient records has billed with 99203 and 10060. As per the CCI EDIT Checker in SUPERCODER, there is no edit to use modifier 25 , whereas as per the cms website, if any significant, separately identifiable evaluation and management [E/M] service by the same physician on the same day of the procedure or other service, we need to use modifier 25 with an e&m.. But as per supercoder edit, if we do not use modifier 25, will be there any denial. Can we bill without modifier ...

Please make me clear on this.Thanks in advance for your replies......


Stuart, Florida
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Assuming the dr documented the e/m (since this is a new patient, I'm assuming the dr did the workup of history, physical exam, etc) and during the same visit decided to also perform 10060, modifier 25 should be appended to 99203. CPT code 10060 has a 10 day global period and when there is a procedure with 0 or 10 days global period, and an E/M is rendered on the same day, append modifier 25 to the E/M.

Our drs perform 10060 and also provide an E/M on the same day and we bill with 25 modifier on the E/M. If not, the E/M will get denied as inclusive to the procedure. 25 overrides that edit, assuming documentation supports and the e/m was medically necessary. Since this was a new patient, I'm sure the dr didn't just introduce himself and then start cutting into the patient. More than likely, the workup for the E/M was done. Now had the patient been seen prior, and this was a follow up from the 1st visit, and the dr decided to perform 10060 and provided no other workup or assessed any other issues, I'd say bill just 10060.


True Blue
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I'm sure the dr didn't just introduce himself and then start cutting into the patient.

You are correct that Dr didn't just introduce and start cutting but some of that other stuff is also included in the 10060. Whether the patient is new or established is not part of the equation when it comes to deciding if an E&M should be reported separately. Minor E&M is always included in a minor procedure.

To the initial poster, you need to learn not to rely on you encoder so much. E&M w/ procedure is not an NCCI edit. Its more looking at situations where modifier 59 come up. If E&M is significant (keyword) and separately identifiable and on same day as a minor procedure, modifier 25 will always be required on the E&M