Office E/M with modifier 25


Lake Charles, LA
Best answers
If someone could help with this scenario......

Patient in cardiology office for 1 year follow up and echo regarding hypertension, cad, stenosis( echo was scheduled the same time as the 1 year follow up). Echo was done same time as encounter and reviewed, medically appropriate history and exam performed. Provider bills 99214-25, 93308. Even though, the echo was scheduled with follow up at previous visit (1 year ago) is it still appropriate to report both the E/M and ECHO?

EKG, ECHO, STRESS TEST, ETC have a XXX indicator so the global concept does not apply, so are these procedures more less exempt from the rule unless they are scheduled strictly for the procedure and the provider only does a limited exam pertaining to the medical necessity of the procedure? I want to make sure I clearly explain this to our providers because they do bill a lot of E/M's with same day test. Any guidance is appreciated!!


True Blue
Best answers
Disclaimer: cardio not my wheelhouse.
My understanding is that en echo would provide information about cad and/or stenosis, but not hypertension. If the provider is also evaluating hypertension (perhaps adjusting/renewing medications), I would feel comfortable with 9921___-25. If the echo is showing a worsening and the provider is adjusting a treatment plan, again, 9921___-25.
If the note is simply:
Pt with hx of htn, cad & stenosis here for echo.
Exam: heart RRR, lungs CTA, BP: 122/84
Echo results show no changes. F/up 1 year for repeat echo.
The work above is included in the reimbursement for the echo.
Historically, -25 is an overused/misunderstood/abused modifier. -25 is SIGNIFICANT and SEPARATELY IDENTIFIABLE E/M on same day as a procedure.
Take the documentation. Cross out everything in the documentation related to (not just performing but related to) the procedure. What is left is the separately identifiable part. Is that significant?

There may be times an E/M with -25 is appropriate, but if it's every echo on every patient, it is highly likely whoever is coding is misunderstanding the use of -25. The procedure has some inherent E/M work built into it.

I would review, and then show my providers this link by American College of Cardiology. In my experience, official guidance from CMS or their specialty society is more likely to really sink in.