Wiki Modifier 25 with OV for Scheduled Prolia/Evenity Injections


Brewton, AL
Best answers
We have a physician that does scheduled Prolia/Evenity injections. We understand that you cannot charge an OV with a -25 modifier when the purpose of the visit is for a scheduled injection. However, we have some questions for anyone who bill these injections. Our physician does a complete ROS, reviews and explains lab results ( labs were performed prior to the visit), and also does a complete physical exam. Where we need clarity is if the review of labs would qualify for the use of a -25 on the OV or is that review part of the prep for the Prolia/Evenity injections? Any input would be greatly appreciated.
Per CMS rules, every procedure (whether major or minor) includes an “inherent” E/M component and, as such, you generally may not report a separate E/M service on the same date of service. This rule is repeated throughout CMS policy documents, but is succinctly explained in the Medicare Claims Processing Manual, Chapter 12, Section 40.1.C:

The “unless” clause is important. It allows you to report (and to receive payment for) an E/M service, along with a minor procedure, if the E/M service is “significant” and “separately identifiable.”

In practical terms, this means:

  1. The medically necessary E/M service must “go beyond” the usual E/M component included as part of the minor procedure.
  2. Documentation must support both the minor procedure and a separate, independent E/M service (e.g., the E/M documentation must “stand alone”). Although it’s not required, best practice is to separate the E/M note from the procedure note.
  3. The appropriate E/M service code must be reported with modifier 25 Significant, separately identifiable evaluation and management service by the same physician or other qualified health care professional on the same day of the procedure or other service appended.
If the labs and PE pertains to osteoporosis or similar to the reason for Prolia treament, the E&M is considered included in the scheduled procedure and should not be billed.
That’s what we were leaning toward as being correct but wanted to reach out and make sure we were on the correct page with this. We are new to these injections and the labs being reviewed honestly had us questioning if there was a chance we could. Thank you for your response on this.