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When is -25 justified?

  1. #1
    Salt Lake North
    Default When is -25 justified?
    Medical Coding Books
    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.

  2. #2
    Our clinics pose the same question to me all the time. My advice to them is that if the patient comes in with a new problem or is a new pt to the provider and treatment evolves into an injection, modifier -25 is probably justified (for that visit only)----probably. however, if its an established patient with an established problem/symptom and the office visit is simply to get a repeat injection/treatment, i would say only the injection is billable. keep in mind there is a small amount of an e/m service in all procedures.

    Other things to consider is:
    -did the provider mention in the previous visit note that he intended on treating the patient with an injection/treament at the next visit? if so, i would say the injection is the only billable charge.

    -are there any changes in injection dosage? if so, chances are there was a minor complication or pt isnt responding appropriately therefore requiring a more detailed history/exam which would probably support an office visit charge and an injection.

    -documentation also plays a key role in this. if the provider is not a clear documenter, modifier -25 may never be supported. on the flip side, if the provider is a good documenter or overdocuments, modifier -25 will probably always be supported but that is when medical necessity comes in to play.

    Good luck....its a tricky area!! its not one of those black or white areas....there is always some grey.
    Dawnelle Beall, CPC, CPMA, CPC-I
    Licensed AAPC PMCC Instructor
    AAPC ICD-10CM Certified Trainer
    Previous AAPC Local Chapter President & VP

  3. #3
    That was a very comprehensive response and I can't really add anything to it. Only, I wanted to say it concerned me that the inquirer's practice routinely adds the 25 modifier and only looks at the ones that deny. Simply because the other ones paid doesn't mean they should have paid. Medicare, for instance will pay but frowns on over-use of that specific modifier and it may prompt an audit. My advise it look at that 25 modifier use in the first place and not after the fact. Good luck. Holly M

  4. #4
    Seacoast- Dover New Hampshire
    Default 25 modifier
    My experience is that you need to know the nature of the visit. Pt comes in for knee pain, then decision is made to inject it, I would then add the 25. If pt comes in soley for injection, then no 25 is needed. Hope this helps.
    Karen Barron, CPC
    Hampton New Hampshire Chapter

  5. #5
    St. Louis, Missouri
    I agree, if the patient is scheduled to get an injection then I would not bill an office visit. If the patient is following up after a previous injection that they received to see how they are doing and the doctor decides to do another injection for what ever reason during the follow up office visit, then I would bill and E&M with a 25 modifier and the injection. The decision to do the injection was made at the time of the current office visit.

    Melissa Blow, CPC

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