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Modifiers used with E/M visit

  1. Default Modifiers used with E/M visit
    Medical Coding Books
    I am asking for everyone's opinion since I am new to the coding world. We have been having problems with insurance companies paying both an office visit and a procedure (ex. 69210 or 31231). This happens most often on established visits, which is understandable. However, we have been using modifier 25 on the office visit in addition to the 69210 or 31231, etc. for all kinds of visits (new, established, consult). Is modifier 25 the correct modifier to be using or like a modifier 51 or 59 on the procedure 69210 or 31231.
    The office is now just billing for the procedure when it comes to an established, but shouldn't the docs get something on a new or consult as far as the office visit and procedure?
    HELP! Thanks!

  2. #2
    Milwaukee WI
    Default Mod 25
    First, is the established patient visit scheduled specifically for the procedure?
    The RVUs for all procedures include appropriate E/M.

    However, if the E/M is truly a separately identifiable service ...
    If the procedure has a 90-day global you need a -57 modifier on the E/M code. If the procedure has a 10 day or less global period you need a -25 modifier. (I'm at home and don't have all my reference materials, so I don't know if the procedures you cite are major or minor.)

    It is pretty much the usual practice for payers to deny the E/M code. I appeal with a letter and the documentation ... that's why you need to be certain that your E/M was truly "significant and separately identifiable."

    F Tessa Bartels, CPC, CEMC

  3. #3
    San Gabriel Valley
    Default modifers with E/M
    Look at your linking of the dx. With 69210 why did the pt come in, ear pain? , link that to your E/M physican has to examin to determine ear impaction.
    Then link impacted cerumen dx to the 69210. Remember to add your modifer 25 to E/M. If your insurance still denies , and your physican documents well, I would appeal the charges.

  4. #4
    North Carolina
    Both of your procedures have a zero day global period. As Tessa mentioned, there are RVU's built into the procedure unless there is a separate identifiable service. 69210 is frequently bundled into E/M codes since there are specific billing/documentation guidelines for this service. The link below provides some terrific information for your scenario.
    Last edited by RebeccaWoodward*; 02-03-2009 at 08:44 AM.
    Rebecca CPC, CPMA, CEMC

    Your click COUNTS...

    CLICK to give FREE mammograms!

  5. Default Denial on Modifier 79
    I have two EM Vists (Estabil pt ) that have been denied due to post op period. The procedure was 17000 the E/M'S were with the same Dr during the
    30 day global. I used modifier 79 and got rejected by Medicare.
    I did use the 25 mod on the original E/M with the cryo (17000). Any suggestions would be appreciated. Thanks, Diane CPC

  6. #6
    North Carolina
    I think I understand your scenario.....

    Patient was in a 30 day global period. During the global period, the patient came in for an office visit and 17000. Couple of things...

    1st- Our region has a LMRP for 17000. Does your diagnosis meet medical necessity?

    2nd-If your office visit was truly a separate, identifiable service, you will add modifiers 24/25.


    17000-79 (with a medically necessary dx)

    Does this help?
    Rebecca CPC, CPMA, CEMC

    Your click COUNTS...

    CLICK to give FREE mammograms!

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