Modifier 25

ROCHELLE

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Boise
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Hello - I have never put modifier -25 on a New pt E/M (99202) with a procedure (11100) for Medicare in over 12 yrs. Has something changed, that I'm unaware of? Thanks for your help.
 

Susan

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Chandler, AZ
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In following the NCCI edits, Medicare typically does not allow for a office visit and a minor procedure in the same day. This is very much dependent on documentation in Medical Decision Making. If you "exclude" the decision for taking the biopsy from the MDM and have nothing else left, then you do not meet the critera for charging a office visit, therefore only leaving you to choose to submit for the office visit or the biopsy. In situations when I find that in addition to the decision to do the biopsy there is more MDM then I will see if an appropriate E&M code can be billed. I hope this makes sense.
 

mitchellde

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Hello - I have never put modifier -25 on a New pt E/M (99202) with a procedure (11100) for Medicare in over 12 yrs. Has something changed, that I'm unaware of? Thanks for your help.
I worked hospital outpatient in 1999 and we had to use it starting then, and I know the physician side had to use it prior to that, I started working the physician side as well in 2000 and it was in place then as well. So I know it has been this way for all of the 21st century at any rate, for when your E&M can support an examination that is beyond that necessary for the procedure performed. Even for a new patient this must be documented. If the new patient came in only to have the bx performed and the provider knew this is what was scheduled, if there is no assessment documented other than an exam of the area in question then you can bill only the procedure.
 

jgf-CPC

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Columbus GA
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Appropriate Usage of Modifier 25:
Modifier 25 indicates that on the day of a procedure, the patient's condition required a significant, separately identifiable E/M service, above and beyond the usual pre and post-operative care associated with the procedure or service performed.
Use Modifier 25 with the appropriate level of E/M service.
The procedure performed has a global period listed on the Medicare Fee Schedule Relative Value File.
An E/M service may occur on the same day as a procedure and within the post-operative period of a previous procedure. Medicare allows payment when the documentation supports the 25 modifier and the 24 modifier (unrelated E/M during a post-operative period.)
Use Modifier 25 in the rare circumstance of an E/M service the day before a major surgery that is not the decision for surgery and represents a significant, separately identifiable service.
 
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