Wiki New vs. Est

[cbosi1]

When billing a new patient annual/preventive code, can you bill a NEW patient E/M code with the 25 mod? My doc thinks you have to use the established code for the office visit, but I was taught that you would use new for both. Thanks so much in advance.

 

[cjtown]

In researching this question, I also have learnt something new.
Per: Modifier 25 Fact Sheet (novitas-solutions.com)
Do not append the following E/M codes that are clearly for new patient only:
92002
92004
99201-99205
99341-99345
Note: The codes listed above are listed as new patient codes and are automatically excluded from global surgery package edit. They are reimbursed separately from surgical procedures. A modifier is not required if visit meets significant and separately identifiable guidelines.
Per CMS reference: Medicare Claims Processing Manual (cms.gov) Medicare Claims Processing Manual Chapter 12 - Physicians/Nonphysician Practitioners

Per Palmetto: Palmetto GBA - JM Part B - E/M Weekly Tip: Significant, Separately Identifiable Evaluation and Management Service
New patient codes (e.g., CPT codes 92002, 92004 and 99201–99205) are automatically excluded from the global surgery requirements and would not normally require CPT modifier 25 to be separately reimbursed from a surgical procedure.
However, if the new patient code and surgical procedure is a National Correct Coding Initiative (NCCI) combination, CPT modifier 25 might be required

• New patient CPT codes require CPT modifier 25 when a separately identifiable E/M service is performed the same day as chemotherapy or non-chemotherapy infusions or injections as these are not considered surgery. For example, CPT codes 96401 and 96372.

It apparently is related to the reason for use as well as the NCCI edits for the code selection.

Hope this helps,
Carla

 

[dkindelt]

When billing a new patient annual/preventive code, can you bill a NEW patient E/M code with the 25 mod? My doc thinks you have to use the established code for the office visit, but I was taught that you would use new for both. Thanks so much in advance.

My understanding is consistent with your physician. Once a new prev med is completed, the patient is established for E&M at the same visit.