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Modifier 25 for Nurse Practioner OV on same day as chemotherapy

  1. Question Modifier 25 for Nurse Practioner OV on same day as chemotherapy
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    Our nurse practitioner sees patients who have new problems on the same day they are receiving chemotherapy. Since they are new problems and non incident to they are billable to the NP and billed out in the NP's name. Therefore a -25 modifier is being used on the NP e/m service (99213/99214) and the chemo services (96413/96411 etc..) are billed out under the drs name.

    We have recently been told we can not bill for the NP visit since the -25 modifier is for a seperate service peformed by the "SAME" physician on the same day and since 2 diffferent providers are providing the services the NP service is not billable.

    Has anyone heard of this or have any information on this?

    Thank you.
    Last edited by bmay; 01-25-2014 at 09:23 AM.

  2. #2
    If the patient is not having any other E&M that day within that Group there is no need for the 25 modifier at all. The Chemo admin is considered a procedure, so, unless another provider also renders an E&M you are over using the 25 modifier.

  3. Default
    The NP is a part of the oncology group. It is her and 2 drs.

    So you are saying to bill the NP office visit we don't need to use the 25 modifier at all and it wont deny against the 96413 also billed on that day?

    And it is ok to bill one service to the NP and one service to the Dr on the same date without the 25 showing it was 2 seperate services?

    We have just yesterday had an auditor tell us we were not allowed to do this and that the 25 modifier was only if it was the same provider and we could not bill the NP service at all.


  4. #4
    Nashville AAPC Chapter
    Only if that NPP bills with a different tax ID# and with their own NPI# would a modifier 25 not be necessary, carriers will not consider them in the same group/practice.

    I wholeheartedly disagree with jabowen with his/her information due to my extensive 12 year experience in Oncology coding and billing working appeals/denials. I do agree that the modifier 25 does state "Same provider", but we have to understand that if the NPP is part of the same group practice as the oncology physicians reporting the infusions and shares a tax ID #, all carriers will require a modifier 25 to support a separate E&M service. Don't take the verbiage of the description quite so literally and understand the whole picture of this scenario. Because the NPP is considered the same specialty as the physicians within the same group taxonomy number.

    Think of it similar to the methodology regarding the definition of a New vs an Established status of a patient, same specialty - same practice, they are considered to be one and the same. Just because the infusion services are billed under the provider, does NOT exclude the need for the modifier 25. According to the Medicare NCCI Coding Manual, a modifier 25 is still needed when an E&M service is performed with procedures that have a global status indicator of XXX, which would be the infusion/injection codes (eg. 96413). It isn't overuse, it's correct coding. Think of modifiers as key's to pass the filters at the carriers computers, no key and it's not going to get in the door and it will auto-deny.

    NCCI Coding Manual - Chapt 1, General Coding Guidelines~
    This E&M service may be related to the same diagnosis necessitating performance of the XXX procedure but cannot include any work inherent in the XXX procedure, supervision of others performing the XXX?procedure, or time for interpreting the result of the XXX procedure. Appending modifier 25 to a significant, separately identifiable E&M service when performed on the same date of service as an XXX procedure is correct coding.
    Last edited by OCD_coder; 01-25-2014 at 01:51 PM.

  5. Default
    Thank you OCD coder. We have been billing these office vists under the NP with the 25 modifier when not incident to for the last year since the NP has joined our practice and have not had an issue until yesterday when an auditor told us we were in correct in using the 25 it was only to be used when the SAME provider is performing both the chemo and the e/m service. Our thought was in other coding instances they are considered the same provider why not this instance. So I came on here looking for other coders opinions.

  6. #6
    Nashville AAPC Chapter
    Keep doing what you have been doing then as you will get denials if you remove the mod-25, I guarantee it. I would ask how much experience the auditor has in billing these scenarios as auditors can make miss-interpretations too and they should be able to back up their recommendations with accurate and defendable information. I provided Medicare rules to defend the way you have billing as accurate and correct.

    It's good to question information that doesn't make logical sense, it's how we all learn.

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