Wiki Modifier 25

[WendySPeters]

We have a couple claims that have modifier 25 on them that the physician and I agree on however, we want to be sure we are thinking correctly.

1 scenario is a patient comes in to have a hemagioma removed from ear. our coder billed E&M w/modifier and the excision code. The physician and I do not think the modifier should have been used nor should the E&M have been billed.

2. same scenario as far as I'm concerned is pt comes in for drainage of elbow notes state specifically he withheld meds for this procedure. NO modifier as far as I'm concerned coder appended w/modifier 25.

3. different scenario pt. comes in for eyelid issues while provider is examining pt she discovers irritated skin tags, and actinic keratosis. Provider decides to use cryotherapy x3 E&M was appended w/modifier 25 however ALL diagnosis were entered on both line items. My knowledge is the modifier is correct in this scenario however, the skin tag and keratosis should not be on the E&M.

Please advise on how we should have billed these three visits. so I can pass info on to my physician.

Thank you very much
Wendy

 

[Chelle-Lynn]

As always, to code anything you would need a copy of the medical records to ensure that there is not documentation that your coder is seeing that may justify the use of the modifier 25. However, in a general scenario...

1 scenario is a patient comes in to have a hemagioma removed from ear. our coder billed E&M w/modifier and the excision code. The physician and I do not think the modifier should have been used nor should the E&M have been billed.
Unless there were unusual circumstances or documentation, if the patient came in with intent to have the hemagioma removed from the ear and the services rendered related directly to that condition it would be unusual to bill for the E&M and the procedure code.


2. pt comes in for drainage of elbow notes state specifically he withheld meds for this procedure. NO modifier as far as I'm concerned coder appended w/modifier 25.
Unless there were unusual circumstances or documentation, if the patient came in with intent to have elbow drained and the services rendered related directly to this procedure it would be unusual to bill for the E&M and the procedure code.

3. pt. comes in for eyelid issues while provider is examining pt she discovers irritated skin tags, and actinic keratosis. Provider decides to use cryotherapy x3 E&M was appended w/modifier 25 however ALL diagnosis were entered on both line items. My knowledge is the modifier is correct in this scenario however, the skin tag and keratosis should not be on the E&M.
Yes, the diagnosis related to the skin tag and keratosis would normally be tied to the procedure only and not the E&M.

Please keep in mind that this is a general response and that all coding should be based on the documentation for each individual account. I would encourage you to continue the conversation with your coder to better understand what they are looking at that is different than what you are seeing. Communication is key in these situations.

 

[ddavis024]

Agree Modifier 25

I agree with Chelle-Lynn. No mods on first two, but the last one. Make sure the coder is paying attention to the linking for each service.

Dana CPC