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25 Modifier

  1. #11
    Seacoast- Dover New Hampshire
    Exam Training Packages
    I am a coder and biller. I code for family, Int Med and Obgyn. Some on my Docs rely on me to pick up on the OV w/Procedure. I always pull the note and make sure the document warrants the code. A pt will make an appt for shoulder pn Doc accesses and decides to do an injection so it gets the ov w/25 and proper inj procedure. If pt comes in for the shot only, then no E&M is warranted because the CC was for inj only.
    Last edited by kbarron; 07-17-2009 at 06:49 AM. Reason: s/b 25 not 26
    Karen Barron, CPC
    Hampton New Hampshire Chapter

  2. #12
    Milwaukee WI
    Default Biller should NOT automatically add -25
    I do not think the billers should be automatically adding the -25 modifier.

    As many times as I've explained to our physicians that if the reason for the visit was to have the procedure (e.g. injection or burn dressing change), then there is no separatley identifiable E/M UNLESS they are evaluating and managing something else entirely ... I have one provider who ALWAYS marks the E/M on every visit.

    Our billers will put through the charge (WITHOUT the -25 modifier), just as it was marked on the superbill and then it will eventually appear on my global denial report. ARRGH!

    But, as frustrating as it is, I'd rather have it this way than be sending through fraudulent claims and getting reimbursed for a "significant separately reportable" service that was neither significant nor separately reportable.

    Just my two cents ...

    F Tessa Bartels, CPC, CEMC

  3. #13
    Quote Originally Posted by jegaydos View Post
    Why would the provider bill for an E/M AND a Procedure, if they didn't INTEND to have the E/M paid for as a separate procedure, as denoted by a -25 modifier ?

    The third-party biller is ASSUMING that you want the E/M paid for, which is why you listed they added the -25, so that it would be paid...nice guys...

    It is the Provider's responsibility, in my opinion, "always", to know WHAT they are BILLING, and what they are being PAID for...and that their records document this fact.

    I would notify your providers of what is happening, so that your concerns are noted in your communications with them, and let them decide how to proceed. What happens next is none of your concern.

    Dr G
    I think you misunderstood what she meant by her post. The fact that the E/M may need a modifier is NOT what is in question. The fact that a biller, that has no coding experience whatsoever (as far as anyone knows anyway), is adding a modifier as common practice without having the documentation to review.
    If they think that it needs a modifier appended, then they should notify the provider, who they happen to work for, let them decide whether or not to add it, and maybe let them know if they may think it is being billed improperly, and leave it up to the provider to decide how to bill their own charts. If they have useful examples or ideas to share with the provider on how they think things get paid for, etc., then great, let them share the info with the provider. But how do they know whether or not is a seperate identifiable charge? You can't bill just to get paid. If it isn't document...You Can't Bill For It.

  4. #14
    It is absolutely not right for the biller to append modifier 25 without review of documentation. Actually, the biller should enter code on claim as the physician has it on super-bill without mod 25. This will definitely be denied by the 3rd party payer at that point, an appeal with medical records may be sent for review. In case of an audit the biller would definitely be in trouble. I work for a third party payer vendor and we review documentation of over 85% of claims submitted with modifier 25. There are lots of providers that understand how to use this modifier and use it appropriately, nonetheless, there are several and I mean several who abuse this same modifier.

  5. Default
    Another possible solution could be for all fee tickets with E/M and procedure be routed through you before going to the billing company for "data entry". And in the meantime, education to both the billing company on the inappropriateness of changing the submitted bills and the providers on the appropriateness of adding an E/M to a procedure.

  6. #16
    Thanks guys for the responses. I'm not employed for this practice or physician, I'm consulting and assessing their billing practices and functions. I wanted to get some input. I agree with not adding mod 25 unless the documentation is reviewed by someone who has coding experience, or is certified, or by the physician themselves.

    However, I will present both sides of the coin and how they proceed is their decision.

    Thanks a whole lot!

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