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Modifier 25 with new patient e&m

  1. #1
    Laguna Niguel
    Default Modifier 25 with new patient e&m
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    Is it appropriate to append modifier 25 to new patient E&M?
    Please help.
    Thank you!

  2. #2
    Modifier 25 can be tricky, but our MAC has some good pointers.

    According to Noridian (which I think is your MAC as well):

    "Do not append to E/M codes that are explicitly for new patient only (CPTs 92002, 92004, 99201-99205, 99321-99323 and 99341-99345). These codes are listed as new patient codes and are automatically excluded from global surgery package edit. They are reimbursed separately from surgical procedure and no modifier is required if visit meets significant and separately identifiable guidelines"

    Except if the procedure is chemotherapy or injections:

    "New patient CPT codes are required when a separately identifiable E/M service is performed same day as chemotherapy or non-chemotherapy infusion or injections as these are not considered surgery"


    Hope this helps answer your question!

  3. #3
    Laguna Niguel
    Yes, thank you very much

  4. Default
    And remember that minor procedures (codes with 0 or 10 postop days) include any E/M related to them. Even for new patients. So the E/M for new patients must be separately identifiable and unrelated to any minor procedures performed/billed on that same DOS.

    The NCCI guidelines state...

    If a procedure has a global period of 000 or 010 days, it is defined as a minor surgical procedure. E&M services on the same date of service as the minor surgical procedure are included in the payment for the procedure. The decision to perform a minor surgical procedure is included in the payment for the minor surgical procedure and should not be reported separately as an E&M service. However, a significant and separately identifiable E&M service unrelated to the decision to perform the minor surgical procedure is separately reportable with modifier 25.

    The E&M service and minor surgical procedure do not require different diagnoses. If a minor surgical procedure is performed on a new patient, the same rules for reporting E&M services apply. The fact that the patient is “new” to the provider is not sufficient alone to justify reporting an E&M service on the same date of service as a minor surgical procedure. NCCI does contain some edits based on these principles, but the Medicare Carriers have separate edits. Neither the NCCI nor Carriers have all possible edits based on these principles.
    Karl M. Ellzey, BAE, CDC, President
    Ellzey Coding Solutions and online coding tools

  5. #5

    If documentation doesn't show that "Significant, Separately Identifiable Evaluation and Management Service by the Same Physician on the Same Day of the Procedure or Other Service", then you probably shouldn't even think about using Modifier 25.
    Last edited by Pathos; 05-16-2018 at 04:57 PM.

  6. #6
    Laguna Niguel
    Thank you!

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