Wiki Modifier 25 with 99223 and 99497

[aim016]

Our palliative care provider is billing 99223 and 99497 together when seeing a patient in the inpatient setting. I put modifier 25 on the 99223 but have since read something that states it would go on the 99497. Does the modifier 25 go on the 99223 or 99497?


Thank you!

 

[Deborah Marsh]

Hi – Have you seen if the payer accepted the 99223-25? It’s an interesting question. There is a Medicare 99223/99497 edit, and 99497 pays less, which may be a factor if mod 25 affects payment for a specific payer. But payer policy may state which code gets the modifier. For instance, https://prc.hmsa.com/s/article/Advance-Care-Planning states, “When billing ACP service with E/M services a modifier code must be appended to the E/M code to ensure that both services are paid when appropriate. Modifier 25 would generally be used for this purpose.” The article (not a policy) at https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5144846/ says, “When billing an additional procedure code (that is not designated in CPT as an “add-on” code), modifier −25 should be added to the E&M code. In these instances, documentation must support that the E&M service was a significant and separately identifiable service above and beyond that of the ACP represented by code 99497.” In both cases, they seem to be saying 25 goes on the non-ACP E/M code, although it isn’t entirely clear because 99497 is in the E/M section.

 

[LASobral]

Based on NCCI guidelines, modifier 25 would be appended to CPT 99497 when reported with 99223 when appropriate. For this NCCI edit pair, CPT 99223 is the column 1 code and 99497 is the column 2 code. Also, there is guidance published in LCA A58664 which states "CPT® instructions note that CPT® codes 99497 and 99498 may be billed on the same day or a different day as most other E/M services, and during the same service period as transitional care management services or chronic care management services and within global surgical periods. These codes may be separately reported when performed on the same date of service in conjunction with the following E/M services: 99201-99215, 99217-99226, 99231-99236, 99238-99239, 99241-99245, 99251-99255, 99281-99285, 99304-99310, 99315-99316, 99318, 99324-99328, 99334-99337, 99341-99345, 99347-99350, 99381-99397, and 99495-99496. Both codes should be reported with modifier-25 added presuming the requirements for use of modifier-25 are met."