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Proper use of 25 modifier

  1. Thumbs up Proper use of 25 modifier
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    Hi

    We had a Conversation going on in our office regarding usage of 25 modifier along with E&M 99213 (Outpatient visit) Were patient came with the complaint of Painless bleeding during bowel movements after examining the patient physician found that patient is having Bleeding internal hemorrhoid were he decides to do a Hemorrhoidectomy by rubber band ligation(s) on the same office visit and performed the procedure

    Dx codes: K64.8

    99213-25 ? -K64.8
    46221-K64.8

    We are being advised that we cannot use E&M 99213 with 25 modifier for the above scenario

    Anyone with feedback on this would be greatly appreciated..
    Last edited by ARON-A; 08-08-2018 at 10:20 PM. Reason: For adding more description

  2. Default Proper use of 25 modifier
    Hai,


    As above scenario patient came for painless bleeding so physician identified as Bleeding internal hemorrhoid and performed the procedure on same day. So it qualifies significantly identified E/M, so you can add 25 modifier with E/M CPT 99213.

    99213-25, K64.8
    46221-K64.8


    Regards,
    SK.MD.AFZAL , CPC
    Senior coder
    Last edited by afzal3193; 08-09-2018 at 02:54 AM.

  3. #3
    Default
    I would start by asking who advised you that you cannot use this, and what was there rationale. Did they actually review the documentation? It's impossible to say with any confidence whether or not the modifier use is appropriate without seeing the notes.

    A modifier 25 requires documentation that supports that a 'significant, separately identifiable evaluation and management service' was performed by the physician, which would need to be an E&M service that is above and beyond the normal pre- and post-operative service that would accompany a minor procedure. And per CMS, the initial evaluation and decision to perform the procedure alone is included in the global package of minor procedures, so the documentation has to reflect that there was more than just that involved. I'd recommend reviewing the documentation and making a determination as to whether or not you feel it supports a separate service and meets this definition of the modifier. If it does, then I would query the individual who told you that you cannot bill the E&M with the 25 modifier and have them explain their reasoning for making this statement. Modifier 25 is a difficult area, and not everyone always agrees exactly on what does or does not support the modifier, but the documentation must always have the final say, not the 'scenario'.
    Thomas Field, CPC, CEMC

  4. Red face Thank you
    Quote Originally Posted by thomas7331 View Post
    I would start by asking who advised you that you cannot use this, and what was there rationale. Did they actually review the documentation? It's impossible to say with any confidence whether or not the modifier use is appropriate without seeing the notes.

    A modifier 25 requires documentation that supports that a 'significant, separately identifiable evaluation and management service' was performed by the physician, which would need to be an E&M service that is above and beyond the normal pre- and post-operative service that would accompany a minor procedure. And per CMS, the initial evaluation and decision to perform the procedure alone is included in the global package of minor procedures, so the documentation has to reflect that there was more than just that involved. I'd recommend reviewing the documentation and making a determination as to whether or not you feel it supports a separate service and meets this definition of the modifier. If it does, then I would query the individual who told you that you cannot bill the E&M with the 25 modifier and have them explain their reasoning for making this statement. Modifier 25 is a difficult area, and not everyone always agrees exactly on what does or does not support the modifier, but the documentation must always have the final say, not the 'scenario'.
    Thank you for the feedback which you gave for the above scenario but still there is one more scenario to go i would like to post it if you wish to have a look over on that

  5. Default Thank you
    Quote Originally Posted by afzal3193 View Post
    Hai,


    As above scenario patient came for painless bleeding so physician identified as Bleeding internal hemorrhoid and performed the procedure on same day. So it qualifies significantly identified E/M, so you can add 25 modifier with E/M CPT 99213.

    99213-25, K64.8
    46221-K64.8


    Regards,
    SK.MD.AFZAL , CPC
    Senior coder
    Thank you for the feedback , The same was actually my understanding

  6. #6
    Default
    Hello, in this particular scenario, I would append -57. In our office we perform E/M on the same day as procedures and when it's in office -25 is appropriate. Ex: injections, minor procedures, etc. When we end up evaluating a fracture, then determining it must be reduced in the OR (Example), Modifier -57 would be appended. Modifier -57 should be appended to E&M visits when surgery will be performed in the next 24 hour time frame in order to unbundle the office visit.
    Ryan Raich, CPC COSC

  7. Red face minor procedure
    Quote Originally Posted by RyanRaichCPC View Post
    Hello, in this particular scenario, I would append -57. In our office we perform E/M on the same day as procedures and when it's in office -25 is appropriate. Ex: injections, minor procedures, etc. When we end up evaluating a fracture, then determining it must be reduced in the OR (Example), Modifier -57 would be appended. Modifier -57 should be appended to E&M visits when surgery will be performed in the next 24 hour time frame in order to unbundle the office visit.
    Hi

    Here procedure done is Hemorrhoidectomy by rubber band ligation (46221) its a minor procedure with the 10 days global period , were 57 modifier can be appended only for decision making for a major procedures , so i think 57 modifier would not be appropriate for the above scenario

  8. #8
    Default
    Hello, I thought this procedure had a longer global. I do apologize and agree with mod -25 then.
    Ryan Raich, CPC COSC

  9. Default
    Quote Originally Posted by RyanRaichCPC View Post
    Hello, I thought this procedure had a longer global. I do apologize and agree with mod -25 then.
    Hai

    Thank you for the feedback But I appreciate the thought you put forward on -57 modifier, All is well

  10. Default Thank you
    Quote Originally Posted by ARON-A View Post
    Thank you for the feedback which you gave for the above scenario but still there is one more scenario to go i would like to post it if you wish to have a look over on that
    Ya I agree with you, my understanding was also same.

    Regards,
    SK.MD.AFZAL, CPC
    Senior coder

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