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25: Is it a Separate Service?

  1. #1
    Default 25: Is it a Separate Service?
    Medical Coding Books
    I need your help. I was asked by my area director to make sure that what I did/do is correct in reference to modifier 25. We have different interpretations of it and he asked that I get other coder's input on it and who better than my fellow HMA buddy.

    We had a pt that came into our Urgent Care center w/ a lesion on his arm which was his only complaint and reason for the visit. The doctor did a Comprehensive exam and then decided to do an I&D. I didn't bill for the exam because I didn't feel that this met the requirements for a 25 modifier which is a Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure of other service.

    He feels that each pt that is seen needs to be evaluated by the doctor prior to any procedure to determine what needs to be done and that justifies a separately identifiable E&M service and is therefore billable. I don't feel that way, I think it then becomes preoperative unless the patient is being seen or evaluated for another condition above and beyond the PRIMARY reason for the visit, in this case the lesion.

    What's your take on this?
    adrianne, cpc

  2. #2
    Default separate service
    I guess I can see where this would go either way. I agree with you that not all visits should include an E/M if they have a procedure. But, in the instance of this lesion, I think they could possibly do an E/M also. They did come in with a lesion, but the decision to do an I&D is made during the exam. That's not a given outcome (of course I don't have the notes).
    Any other takers?

  3. #3
    Kingsport, TN
    I agree. Unless the physician knew that he was going to do the I&D up front, then I would charge an E/M as well as the procedure(If all criteria is met).

  4. #4
    The documentation is what you would expect. It's a history, exam and mdm of a needed I&D. All surgical procedures, minor or major, require some preop care. How do you separate the preop, which is not billable, from the E&M services and bill for an exam. How is this a billable charge? I see it from both sides. I do believe the doctor deserves to be paid for his services and I do think an exam is necessary, I just don't think this is what this modifier was designed to do. Every procedure is designed to have a little E&M included in it, call it the preop. If the doctor doesn't go above and beyond this, I don't believe you have a charge. Is it the MDM that's the deciding factor? I don't know, that's where I need the input. The more the better. I'm interested in everyone's opinion. I know I'm not the only coder out there that thinks this way and I would like to hear from others.
    adrianne, cpc

  5. #5
    Greeley, Colorado
    I understand that all procedures include some component of an E/M. I think that if the MDM is ultimately where the decision to perform the procedure occurs, then you should be able to code the E/M with mod -25 and the procedure. Just my opinion.

    Obviously, if the patient is schedule for the procedure then no E/M should be reported in relation to the procedure.
    Lisa Bledsoe, CPC, CPMA

  6. #6
    Seacoast- Dover New Hampshire
    Default E&M and IUD removal
    Would this also apply to remove IUD? Pt comes in w/abd pn, MD decides to remove the IUD. As this is not the primary reason for the visit I believe that a 25 should go on the E&M.
    Karen Barron, CPC
    Hampton New Hampshire Chapter

  7. #7
    I agree with the use of the 25 modifier for both instances (IUD & lesion scenarios)

    Mary, CPC,COSC

  8. #8
    Default I agree with your doctor on this one...
    The first thing that jumps out at me is the statement "comprehensive exam", a comprehensive exam is not included in any procedure RVU that I am aware of.

    The second thing is the intent of the visit. The patient came in because of a lesion. I&D is not the default treatment for every patient with a lesion and since this was a new problem to this provider the intent was to be evaluated and determine a course of treatment.

    I think this scenario is a good example of why there is a 25 modifier. He could have told the patient to schedule an appointment with their regular doctor to have the procedure done but he chose to do then it instead. I think he clearly provided 2 services.

    Just my opinion,

    Laura, CPC

  9. Default I am still not clear?
    We have the same issue going on here in my hospital in the emergency room where I work. I have one physician who is very thorough and will do a full history and physical on his patient's (comprehensive exam) and proceed to do a procedure. In his case, since I have the documentation to support a separate service, am I justified in coding an separately identifiable E & M code with the '25' modifier or can I only do that if he picks up and treats separate diagnoses with this separate exam as someone (non-certified in coding or billing) has told me.

  10. Default
    Are you saying if he had not done a comp exam then a 25 wouldn't be appropriate? This is what I'm trying to figure out. What exactly makes this separate?
    adrianne, cpc

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