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25: Is it a Separate Service?

  1. #11
    Medical Coding Books
    No, I think the 25 is appropriate in this situation regardless of the exam elements done. The fact that it was a comprehensive exam just tips the scales even more in my opinion.

    I have always been told that the amount of E/M built in procedures is very minimal. Enough so that it can not stand alone and is only related to the area being treated.

    Laura, CPC

  2. Default
    Okay, so -25 shows that the office visit was ABOVE and BEYOND than what a "typical" office visit is for. The lesion scenario, I can totally see what she is saying in that the patient goes in for lesions, gets and I&D, and leaves the office. Say you bill a 99213-- yes, the visit was done and during the visit, a decision to go ahead and treat the leasion was made. MDM was rather low at that point since it was able to made right then and there. Provider also performs the I&D and yes, that is also able to billed. HOWEVER, I see no place for a -25 modifier because the office visit itself was FOR the lesions. Period.

    IF...the patient went in and had lesions checked out, and DURING the visit, says, "doc, hey, I got these really bad warts on my feet too-- mind taking a look at them while Im here?" THAT is when 25 can be reported. Because the original office visit for the lesions no longer was JUST for the lesions-- the doc also inspected Patient X's feet. In turn, he can bill with a -25 modifier in order to receive correct reimbursement for BOTH types of service offered in ONE office visit.

    Make sense?

  3. #13
    What was the physician's intent when the appointment was made? Was it to have an office visit and evaluate this lesion. If that is the case an E/M is can be billed with 25 modifier and the I&D also. We have this scenerio come up alot in my family practice office and it's all about the intent of the visit. If it was known prior to the visit that and I&D needed to be done, then no an E/M is not warranted but sounds to me like the Dr. decided to do an I&D within his MDM and should bill the e/m. The I&D was not a "planned procedure", with what info we have received from the poster.
    Roxanne Thames CPC, CPC-I, CEMC

    "Remember the greatest gift is not found in the store but in the heart of true friends"

  4. #14
    Minneapolis MN
    The -25 modifier indicates separately indentifiable - the evaluation of the lesion (first example) is included in the primary procedure and not separately billable. A provider cannot I&D a lesion without evaluating the lesion - adding an officie visit for the evaluation would be double billing.
    For the IUD with ab pain, (second example) since the presenting problem was ab pain, which needed to be evaluated and determine a course of action, I would charge an add'l E/M because the resulting procedure IUD removal, was not what the patient presented for. For the third example, in the ED, just because a provider performs a comprehensive exam does not mean it is medically necessary. Again, if performed to evaluate an issue that would lead to a procedure, then not additonal E/M should be billed. Of course, all my suggestions would need documentation to support any service. With RACs coming to the Midwest soon, we've made some changes in our interpretation of the -25 modifier on the side of being more cautious.

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