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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
    i agree with both of the expressed views but it also depends on the documentation. typically if its a new pt, there is usually a more extensive service performed to warrant the -25. But if its an established patient who presents to the office for lesion and the provider doesnt address other issues in the visit, i would agree with you, the I&D is probably all thats warranted. Again, both scenarios also need to be supported in documentation.

    Hope that opinion helps.
    Dawnelle Beall, CPC, CPMA, CPC-I
    Licensed AAPC PMCC Instructor
    AAPC ICD-10CM Certified Trainer
    Previous AAPC Local Chapter President & VP

  3. #3
    Default Refer to the modifier section
    Please refer to the modifier section for more discussion on this/.
    adrianne, cpc

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