Wiki OCE requiring mod 25

[Jacoder]

I am having issues with a certain denail code I've been recieving from at least 2 insurances. The reject reason says, "This claim contains a significant procedure and an E/M procedure with the same date of service. Unless a modifier 25 is used with the E/M CPT code to indicate that the E/M procedure was a significant, separely identifiable E/M service by the same MD on the same day as a procedure the payment for the service is included inthe payment for the significant procedure."

This is what we billed:

99284 - ER level 4
70450 - CT Head
72125 - CT Cervical Spine

I don't agree with adding the modifier 25. I see an E/M procedure as meaning a doctor evaluated a patient and documented what he evaluated and found, ect. I don't think that x-ray CPT's should count as an E/M service. And I can't say that they are separately identifiable, because the ER assessment and the x-rays were all related. Can someone please explain this to me? Thank you!

 

[mitchellde]

In the facility you have to add a 25 modifier to the E&M when a significant procedure is also billed, a significant procedure is any status S or status T procedure, CT scans are a Status T therefor they are significant necessitating a 25 modifier on the E&M or it will be denied.

 

[Jacoder]

Thanks Debra!