Proper use of 25 modifier

ARON-A

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Hi

We had a Conversation going on in our office regarding usage of 25 modifier along with E&M 99213 (Outpatient visit) Were patient came with the complaint of Painless bleeding during bowel movements after examining the patient physician found that patient is having Bleeding internal hemorrhoid were he decides to do a Hemorrhoidectomy by rubber band ligation(s) on the same office visit and performed the procedure

Dx codes: K64.8

99213-25 ? -K64.8
46221-K64.8

We are being advised that we cannot use E&M 99213 with 25 modifier for the above scenario

Anyone with feedback on this would be greatly appreciated..
 
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AfzalShaik

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Hai,


As above scenario patient came for painless bleeding so physician identified as Bleeding internal hemorrhoid and performed the procedure on same day. So it qualifies significantly identified E/M, so you can add 25 modifier with E/M CPT 99213.

99213-25, K64.8
46221-K64.8


Regards,
SK.MD.AFZAL , CPC
Senior coder
 
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thomas7331

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I would start by asking who advised you that you cannot use this, and what was there rationale. Did they actually review the documentation? It's impossible to say with any confidence whether or not the modifier use is appropriate without seeing the notes.

A modifier 25 requires documentation that supports that a 'significant, separately identifiable evaluation and management service' was performed by the physician, which would need to be an E&M service that is above and beyond the normal pre- and post-operative service that would accompany a minor procedure. And per CMS, the initial evaluation and decision to perform the procedure alone is included in the global package of minor procedures, so the documentation has to reflect that there was more than just that involved. I'd recommend reviewing the documentation and making a determination as to whether or not you feel it supports a separate service and meets this definition of the modifier. If it does, then I would query the individual who told you that you cannot bill the E&M with the 25 modifier and have them explain their reasoning for making this statement. Modifier 25 is a difficult area, and not everyone always agrees exactly on what does or does not support the modifier, but the documentation must always have the final say, not the 'scenario'.
 

ARON-A

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Thank you

I would start by asking who advised you that you cannot use this, and what was there rationale. Did they actually review the documentation? It's impossible to say with any confidence whether or not the modifier use is appropriate without seeing the notes.

A modifier 25 requires documentation that supports that a 'significant, separately identifiable evaluation and management service' was performed by the physician, which would need to be an E&M service that is above and beyond the normal pre- and post-operative service that would accompany a minor procedure. And per CMS, the initial evaluation and decision to perform the procedure alone is included in the global package of minor procedures, so the documentation has to reflect that there was more than just that involved. I'd recommend reviewing the documentation and making a determination as to whether or not you feel it supports a separate service and meets this definition of the modifier. If it does, then I would query the individual who told you that you cannot bill the E&M with the 25 modifier and have them explain their reasoning for making this statement. Modifier 25 is a difficult area, and not everyone always agrees exactly on what does or does not support the modifier, but the documentation must always have the final say, not the 'scenario'.
Thank you for the feedback which you gave for the above scenario but still there is one more scenario to go i would like to post it if you wish to have a look over on that
 

ARON-A

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Thank you

Hai,


As above scenario patient came for painless bleeding so physician identified as Bleeding internal hemorrhoid and performed the procedure on same day. So it qualifies significantly identified E/M, so you can add 25 modifier with E/M CPT 99213.

99213-25, K64.8
46221-K64.8


Regards,
SK.MD.AFZAL , CPC
Senior coder
Thank you for the feedback , The same was actually my understanding :)
 

RyanRaichCPC

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Hello, in this particular scenario, I would append -57. In our office we perform E/M on the same day as procedures and when it's in office -25 is appropriate. Ex: injections, minor procedures, etc. When we end up evaluating a fracture, then determining it must be reduced in the OR (Example), Modifier -57 would be appended. Modifier -57 should be appended to E&M visits when surgery will be performed in the next 24 hour time frame in order to unbundle the office visit.
 

ARON-A

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minor procedure

Hello, in this particular scenario, I would append -57. In our office we perform E/M on the same day as procedures and when it's in office -25 is appropriate. Ex: injections, minor procedures, etc. When we end up evaluating a fracture, then determining it must be reduced in the OR (Example), Modifier -57 would be appended. Modifier -57 should be appended to E&M visits when surgery will be performed in the next 24 hour time frame in order to unbundle the office visit.
Hi

Here procedure done is Hemorrhoidectomy by rubber band ligation (46221) its a minor procedure with the 10 days global period , were 57 modifier can be appended only for decision making for a major procedures , so i think 57 modifier would not be appropriate for the above scenario
 

AfzalShaik

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Thank you

Thank you for the feedback which you gave for the above scenario but still there is one more scenario to go i would like to post it if you wish to have a look over on that
Ya I agree with you, my understanding was also same.:)

Regards,
SK.MD.AFZAL, CPC
Senior coder
 
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