Wiki Neurology Coding Question

[CMart11]

Hi Everybody,

I am the Administrator for an outpatient Neurology practice and my doc asked me to clarify something so I wanted to reach out for some opinions. We perform routine EEG in our office (either CPT 95816 or 95819) often the same day as the patient's office visit (usual outpatient E/M codes 99214, 99205 etc). I have been here for 3.5 years and my doc has been here for almost 6, and we have never appended modifier 25 to the E/M when doing EEG same day, and we have never had an issue with reimbursement. Her question is, should we be appending modifier 25 to the E/M? Are we at risk of getting audited and having to pay back $$ from improperly coded visits and EEGs? Thanks in advance!

 

[sls314]

Hi Everybody,

I am the Administrator for an outpatient Neurology practice and my doc asked me to clarify something so I wanted to reach out for some opinions. We perform routine EEG in our office (either CPT 95816 or 95819) often the same day as the patient's office visit (usual outpatient E/M codes 99214, 99205 etc). I have been here for 3.5 years and my doc has been here for almost 6, and we have never appended modifier 25 to the E/M when doing EEG same day, and we have never had an issue with reimbursement. Her question is, should we be appending modifier 25 to the E/M? Are we at risk of getting audited and having to pay back $$ from improperly coded visits and EEGs? Thanks in advance!

There isn't an NCCI edit between the E/M outpatient visit code and the EEG codes you listed (95816 or 95819). Modifier 25 would be used to override an NCCI edit between a procedure and an E/M visit, and indicate that the E/M visit was distinct & separately identifiable from the procedure.

Since there isn't an edit in your code pair, you don't need the 25 modifier. (With the caveat that there could be an insurance company out there that has strange edit rules that they implement contrary to NCCI and CMS edits.)

Some of the Medicare MACs have an edit checker on their websites - here's a link to the one for CGS: https://www.cgsmedicare.com/medicare_dynamic/j15/ptpb/ptp/ptp.aspx