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Modifiers -51 and -25

hthompson

Guru
Messages
173
Location
Santa Rosa
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While I understand what they mean, their use is being questioned for several circumstances:

Tell me if any modifiers are/n't needed please:

99212-25
94640
J7613
90658
90471

99391
99212-25
99173
92551-51
90660
90473

Thanks so much in advance for your assistance!
 

ajs

True Blue
Local Chapter Officer
Messages
1,086
Location
Tacoma, WA
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0
While I understand what they mean, their use is being questioned for several circumstances:

Tell me if any modifiers are/n't needed please:

99212-25
94640
J7613
90658
90471

99391
99212-25
99173
92551-51
90660
90473

Thanks so much in advance for your assistance!
It is hard to know if the modifiers are needed or not unless we know the circumstances behind the use of these codes. We really need a chart note, or at least a brief description of the encounter in order to give any advice.
 

hthompson

Guru
Messages
173
Location
Santa Rosa
Best answers
0
Level 2 office visit with a nebulizer treatement of Albuterol and a flu shot.
99212-25
94640
J7613
90658
90471

Preventive med visit for a 15 year old with an underlying condition of worsening eczema. Has a Snellen screening and an audiogram along with a flu shot.
99394
99212-25
99173
92551-51
90658
90471

I had to change a few codes for the scenario ;)
 

ajs

True Blue
Local Chapter Officer
Messages
1,086
Location
Tacoma, WA
Best answers
0
Level 2 office visit with a nebulizer treatement of Albuterol and a flu shot.
99212-25
94640
J7613
90658
90471

Preventive med visit for a 15 year old with an underlying condition of worsening eczema. Has a Snellen screening and an audiogram along with a flu shot.
99394
99212-25
99173
92551-51
90658
90471

I had to change a few codes for the scenario ;)
The first scenario should not require the 25 modifier on the E/M. The albuterol treatment excludes E/M services, so you should be able to bill without the modifier.

In the second scenario you do not need the 51 modifier on the 92551. Screening and diagnostic tests do not use this modifier no matter how many different ones are ordered.

If you are going to try to bill additionally the 99212 for the eczema you do need the 25 modifier. The problem there may be that if it is really a Level 2 problem visit, that may not be considered significant enough for additional reimbursement. Be sure there is separate documentation that is clearly enough work up to require the additional code.
 

hthompson

Guru
Messages
173
Location
Santa Rosa
Best answers
0
If I don't put a modifier -25 on scenario 1, will the insurance deny assuming that there was not a need for an office visit with the neb treatment?

I don't code the office visit if the patient came in for a scheduled nebulizer treatment, but some patients come in and need a work up before the neb treatment is ordered. Please explain more clearly why I wouldn't need a -25.
 

ajs

True Blue
Local Chapter Officer
Messages
1,086
Location
Tacoma, WA
Best answers
0
If I don't put a modifier -25 on scenario 1, will the insurance deny assuming that there was not a need for an office visit with the neb treatment?

I don't code the office visit if the patient came in for a scheduled nebulizer treatment, but some patients come in and need a work up before the neb treatment is ordered. Please explain more clearly why I wouldn't need a -25.
If you look at the instructions at the beginning of the section "Other Procedures" (94010 is the beginning code in the section). "Codes 94010-94799 include laboratory procedure(s) and interpretation of test results. If a separate identifiable Evaluation and Management service is performed, the appropriate E/M service code should be reported in addition to 94010-94799". Per this instruction, you should not need to add modifier 25 to the E/M service, but it is allowed if you wish to add it.
 
Last edited:
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