- Salt Lake City, UT
- Best answers
I work in the Pain Management field. Our docs are always billing surgical codes due to injecting pain medication. One of our clinics, they always bill an office visit with a -25 modifier. When the insurance company denies the office visit because it is included with the surgical code, it comes to my desk and my job is to get the office visit paid IF it is justified. My manager and myself (who is also a certified coder) can't agree on "when" one is justified or not. Before the pain injections are done, the doc will always do a regular "work up" (constituional and so forth) before performing the injections, so the question then becomes: What justifies going above and beyond the normal visit that would be included? A different diagnosis is not required per the nomenclature of the CPT. In reading the medical records, I am not seeing anything that would be a "Significant" service. What things do you look for in order to see if -25 is justified? Keep in mind that most of our patients are on Medicare, so we are being watched closely. Any input would be very helpful. Thank you.