Wiki New Patient Medicare Modifier -25

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jeniearle

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I have a new patient who came in for shoulder pain. During the visit, it was determined that they would get a joint injection for relief. I billed a 99202-25 along with the joint injection. Medicare is denying this stating "Modifier 25 is Invalid with this CPT" Can this be appealed or is this a Medicare rule. How should this be billed?

Thank you for any help!:)
--Jeni
 
We run into this all the time with Medicare. Bill it like this...

99202
20610-59

I'll see if I can find documentation.
 
jeniearle said:
I have a new patient who came in for shoulder pain. During the visit, it was determined that they would get a joint injection for relief. I billed a 99202-25 along with the joint injection. Medicare is denying this stating "Modifier 25 is Invalid with this CPT" Can this be appealed or is this a Medicare rule. How should this be billed?

Thank you for any help!:)
--Jeni
Click to expand...

It's possible they made a mistake :)eek:), as modifier -25 is appropriate on the E/M. We don't usually have problems with Medicare denying a scenario like this. If we do, it's because Medicare denied incorrectly.
 
MY carrier is Cahaba, and they deny this scenario every single time! When we called to find out why, they told us to bill the procedure with a modifier-59!! Is it correct coding? No. .. Does it get paid? Yes. I can't explain it any more than you can.
 
Modifier -25 denials...

Just a heads-up to you all...

When you submit a scenario such as the one you cite - 99202-25 and 20610 - which is absolutely correct! ...and you receive a denial, the first line of defense is to resubmit because it is not an appropriate denial. IF your carrier goes as far as instructing you to submit the scenario "incorrectly", get this in writing because the day WILL come when the carrier goes after you for submitting charges inappropriately for the purposes of getting paid.

Sometimes, I think CPC stands for CERTIFIED PARANOID CODER...insurance companies don't always behave according to Hoyle and we, as coders, must protect ourselves...so, make the insurance companies responsible for ALL misinformation they out out there.

Joyce
 
Our Northern California carrier, Palmetto GBA, specifically states on their website and in their Spring '09 Workshop Booklet that they do not want a modifier 25 on a New patient E/M code (this was news to me!).

"This modifier should not be submitted with E/M codes that are explicitly for new patients only: CPT codes 92002, 92004, 99201 through 99205, 99281 through 99285, and 99341 through 99345. These codes are 'new patient' codes and are automatically excluded from the global surgery package, meaning that they are reimbursed separately from surgical procedures. No modifier is required in order for these codes to be separately reimbursed."

Sounds like your carrier does the same.
 
Actually, I've seen the 'no -25 modifier for new pt visits' from my local Medicare carriers too. However, I also recall a ruling that suggested that the '57' (Decision for surgery) modifier should be used for new pt visits and '25' should be used for established pts. I've used this rule of thumb for years with few problems...or at least problems that couldn't be overturned.

Brock Berta, CPC
 
That would work, except that the case in the original post was a joint injection 20610. Since this procedure has less than a 90 day global period, the mod-57 should not apply.
 
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