modifier-25 for radiology in physician Office

ugocodergirl

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Can you please let me know if your practice adds a -25 in the physician office/clinic setting when an xray is done in the office. As a remote/traveling coder all of the clinics I've coded for have not applied a -25; but now I'm coding in a hospital with managers that are well informed, and they state that office setting is different from outpatient. I know that in out patient if the procedure has an X or A status indicator it's not necessary, and the codes are usually appended if they do a procedure with an S or T status indicater. Can you please include a source? I read the CMS info that included a -25 with radiology, but it also included another procedure. Wouldn't the work done by the physician be picked up with the -26? Please help me; I really like to stay updated on the most ucurrent info. Does adding the -25 increase the revenue? Wouldn't that create a red flag, if they do xrays all the time?
 

pwilkie

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Modifier 25

My understanding of 25 is that it identifies a separate E/M service performed during the same session as a procedure. So if the radiologist performs an E/M at the same time as the x-ray and it was medically necessary they could use it on the E/M code.
 

ugocodergirl

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In my documentation I only see the physicians documentation that an xray was done; then I get a radiology report; then a note from the doctor summarizing the report. What extra procedure has the physician done? If he read and interpreted the report that would be covered in the EM; so I don't see how that is seperate.
 

jmcpolin

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Is your radiologist seeing patients in the office and doing a history physical and medical decision making on top of reading the xray?
 

OCD_coder

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Please be aware that this requirement for a mod-25 when only a radiology procedure is done is payor driven. Please, please, please find out from the payor if that is what they are really requiring before a mod-25 is added - meaning get their own policy in writing first.

Mod-25 is when a minor surgical procedure is done on the same day as an evaluation and management. Radiology procedures are NOT minor surgery.

By using a mod-25 just to get payment is over use of the mod-25 and it WILL raise red flags. Especially with all Medicare contractors. This is a huge RAC audit trigger and many other payors like BCBS and Aetna are pursuing the same data mining for this issue.
 

ugocodergirl

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Mod -25 and xrai in physician practice setting

Thats what I thought, but we use the 3M system and my manager says that 3m is asking for a -25 for clinics, but not for facility coding.
 

mitchellde

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In the outpatient setting some radiology procedures are a Status S such as MRI and ultrasound, therefore any clinic visits or ER visits also billed on the claim must have a 25 modifier. The same definition applies however meaning if the patient came in for the purpose of the procedure then there can be no E&M billed.
 
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jgf-CPC

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Appropriate Usage
Modifier 25 indicates that on the day of a procedure, the patient's condition required a significant, separately identifiable E/M service, above and beyond the usual pre and post-operative care associated with the procedure or service performed.
Use Modifier 25 with the appropriate level of E/M service.
The procedure performed has a global period listed on the Medicare Fee Schedule Relative Value File.
An E/M service may occur on the same day as a procedure and within the post-operative period of a previous procedure. Medicare allows payment when the documentation supports the 25 modifier and the 24 modifier (unrelated E/M during a post-operative period.)
Use Modifier 25 in the rare circumstance of an E/M service the day before a major surgery that is not the decision for surgery and represents a significant, separately identifiable service.
 
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