Wiki Modifier -25 - your practice codes

[hthompson]

Can you tell me if your practice codes a -25 with E/M for everyone who had something else done during the visit, like 81003 or 87880 or 81025? Do in house labs count as a procedure or service as defined by AMA?

I am trying to get this right because mod -25 was never explained to me properly until a brick hit me in the head yesterday (figuratively speaking).

Now I understand that with 20610, 11200, etc (actual procedures) that I'll add the -25 to the E/M that came with it, but what about labs and such?

 

[Lisa Bledsoe]

Hi Heidi - based on conventional coding you would not need a modifier -25 on your E/M with a lab...HOWEVER - each insurance has their own policy on this. They don't follow what CPT states, so you'll need to check with each of your carriers. Adding mod -25 to all E/M's isn't going to hurt, it just goes against what we've been taught. You DO need it when an actual procedure is performed, such as 20610, etc. You cannot report an E/M if the patient was scheduled for the joint inj. Same for lesion removals, biopsies, etc. Hope that helps. Watch out for those bricks!

 

[hthompson]

I think I just won't use it with labs. There was an OIG investigation in 2005, if I remember, and it said there was a lot of improper usage when practices were putting it on every E/M even when there wasn't a procedure. I don't want to be the cause of any red flags thrown around here

I'm working on my MDs for proper documentation for their procedures and working on the MAs to stop trying to force the MD to put an E/M for every visit because they think the page looks funny w/o it and they were taught that every visit needs an E/M.

I had an MD carry over a superbill by hand with her MA by her side. She wanted me to tell her MA it was okay for her not to bill an E/M for that visit that she did an IUD insertion. I asked her if she ever had an office visit with her pt just to realize the pt needed an IUD? She laughed and said no. So I told her, then you only scheduled the pt for an IUD and that's all you did? She said yes. So I assured the MA that the MD was right in her thinking that it was a procedure only visit. Case closed. My job is done here (for a second or two)