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Modifier 25 help please

Mrutkowski18

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During a normal follow-up at the PCP the doctor orders that the patient have and EKG and CXR at the end of the visit. There is no medical necessity for either procedure and no supporting Dx's. Would I still use modifier 25? I'm a little confused because I don't think they are "significant procedures" since there is no diagnoses to support them.. :confused:
 

btadlock1

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During a normal follow-up at the PCP the doctor orders that the patient have and EKG and CXR at the end of the visit. There is no medical necessity for either procedure and no supporting Dx's. Would I still use modifier 25? I'm a little confused because I don't think they are "significant procedures" since there is no diagnoses to support them.. :confused:
I think you may be confused...I have a couple of questions:confused::
First: Was this a problem-oriented visit (with a Chief complaint, symptoms, chronic illness, etc.), or was it a routine well-check?

Your answer on that, will determine a lot about how you can bill this - if it's routine, you'd bill a preventive E/M 99381-99397, or the appropriate G-code (HCPCS) for a Medicare patient. If using a G-code, there's a chance that the EKG and CXR are included in the office visit, and can't be reported separately, but it's hard to say for sure, with the information provided here.

If there's a complaint (eg, HTN, COPD, etc.), then you'd use a problem-oriented E/M (99201-99215); the diagnosis used for the E/M may or may not be the same as the diagnosis used for 93000 and 71020. 93000 can be performed as part of a routine exam, so it can be billed with a routine diagnosis (eg, V70.0); 71020 will likely deny, if there's no problematic-reason for the procedure, documented - that's not usually a covered preventive benefit.

93000 & 71020 don't bundle into a problem E/M's, or into preventive E/M's (CPT only). As I mentioned earlier, they might bundle into a G-code, such as G0438 - but that's only going to be an issue if it's a routine visit for a Medicare patient (if that's the case, you should check with your MAC for billing instructions).

More than likely, you've got a chief complaint listed there somewhere, and you're overlooking it (they can be tricky to find, sometimes). Without seeing the note, though, it's impossible to say whether or not the EKG or CXR was medically necessary, or what the correct diagnosis would be for those.

Either way, if those are the only procedures billed, your E/M shouldn't require a 25 modifier. You'd only need one, if you bill a procedure/service, that an E/M bundles into (such as an injection administration - 96372, or a breathing treatment 94640). The 25 modifier ONLY goes on E/M codes - never on 93000 or 71020.

If you billed other procedures which would necessitate a 25 modifier on your E/M (such as 96372 or 94640), then it's likely that your EKG will require a 59 modifier, as well. Once again, you ONLY need to add the modifier, if the services bundle, in the first place.

Check NCCI edit tables, if you're unsure, or if you still need help, provide the details from the note (Just copy all of the note, minus any identifying information, like the patient/provider name or DOB). I'll gladly assist, but unfortunately, this is the most help I can be, with limited info. Hope that helps! ;)
 

Mrutkowski18

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Palm City, FL
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Thank you for helping me!

It is a problem focused visit not preventitive. And the patient's insurance is Molina.
Here is the note:

SUBJECTIVE:
The patient is here for follow up. Now the patient last visit had right shoulder discomfort that I injected the cortisone subacromially, that mixed with lidocaine and the patient did not improve at that time, but now the patient seems that the range of motion has been improved. The patient was not able to abduct more than 40 degrees at that time and now the abduction is above 90 and around 110 and 120 degrees but still with discomfort. The patient shows significant improvement.

ASSESSMENT:
1. Right shoulder tendinitis. Now the patient has improved since last visit after injection of corticosteroid, but then again due to lack of the complete improvement of the range of motion, the MRI was requested and has been denied by her insurance. So we are just waiting for MRI to be approved.
2. DJD of the knees. The patient is on Tylenol prn.
3. Osteopenia. The patient's vitamin D level is normal. The patient was advised to continue taking vitamin D and calcium on a daily basis.

RECOMMENDATIONS:
I am just going to get the patient's EKG and CXR today.

NUTRITION: The patient was advised to adhere to low-fat low-salt diet.
RETURN TO OFFICE: 3 months.
 

btadlock1

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Thank you for helping me!

It is a problem focused visit not preventitive. And the patient's insurance is Molina.
Here is the note:

SUBJECTIVE:
The patient is here for follow up. Now the patient last visit had right shoulder discomfort that I injected the cortisone subacromially, that mixed with lidocaine and the patient did not improve at that time, but now the patient seems that the range of motion has been improved. The patient was not able to abduct more than 40 degrees at that time and now the abduction is above 90 and around 110 and 120 degrees but still with discomfort. The patient shows significant improvement.

ASSESSMENT:
1. Right shoulder tendinitis. Now the patient has improved since last visit after injection of corticosteroid, but then again due to lack of the complete improvement of the range of motion, the MRI was requested and has been denied by her insurance. So we are just waiting for MRI to be approved.
2. DJD of the knees. The patient is on Tylenol prn.
3. Osteopenia. The patient's vitamin D level is normal. The patient was advised to continue taking vitamin D and calcium on a daily basis.

RECOMMENDATIONS:
I am just going to get the patient's EKG and CXR today.

NUTRITION: The patient was advised to adhere to low-fat low-salt diet.
RETURN TO OFFICE: 3 months.
I see what you mean - that's a terrible note...Is that really all there is, or was there a physical exam included with it?
Get clarification from the provider as to the reasons for the EKG and CXR - it's not clearly indicated by the documentation (no complaints from chest area, and you wouldn't do a CXR to check for shoulder problems)

EKG isn't indicated, either. Given the quality of this note, I'm not surprised that he couldn't get an MRI approved (and I wouldn't hold my breath, waiting for the payer to change their minds, either). It's too hard to follow the doctor's train of thought...He's included what he did, but he didn't say why he did it, and it's not implied anywhere else in the note.

He doesn't have to write down every last detail of his medical decision making, but he should at least include enough information for an outside observer to be able to connect the dots. You can't code much from this note, unless he makes a good addendum. If there's really no PE documented, I wouldn't even allow credit for anything over 99211, but that's just me...
;)
 

Mrutkowski18

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Palm City, FL
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haha yeah you see my predicament??
The doctor said he did them just to get a baseline, it is a fairly new patient.
And this was not a physical/preventative visit in any way. That's really all there was, anything I left out was even more irrelevant to the 2 procedures than the info I gave.
 

btadlock1

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haha yeah you see my predicament??
The doctor said he did them just to get a baseline, it is a fairly new patient.
And this was not a physical/preventative visit in any way. That's really all there was, anything I left out was even more irrelevant to the 2 procedures than the info I gave.
Well, it sounds like he's thorough, I suppose. But, it's very unlikely that you'll get them to pay. What does he mean by 'baseline' on the CXR? The EKG, I get, but an x-ray? That just sounds wasteful, without any symptoms, or at the very least, some kind of family history of lung cancer, or something...Just my thoughts...
Okay, well...
If neither test had unusual results, I'd say go with V81.2 for the EKG, and V72.5 for the CXR.

Hope that helps! ;)
 
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