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Office Visit with U/S

  1. #1
    Default Office Visit with U/S
    Medical Coding Books
    Payers are denying office visits with OB U/S. Any suggestions?

    Thanks in advance!!!

  2. #2
    Columbia, MO
    Is it due to OB global?

    Debra A. Mitchell, MSPH, CPC-H

  3. #3
    Not due to global

  4. #4
    Please expand on the situation. Why was the u/s performed, why was the patient seen for an office visit?

  5. #5
    Columbia, MO
    I agree more information is needed, if this were an OB ultrasound, then it sounds like it is in the OB global, what makes it not in the global?

    Debra A. Mitchell, MSPH, CPC-H

  6. #6
    ..but aren't OB U/S paid separately from the OB global package

  7. #7
    Columbia, MO
    Yes but the office visit is not. You said they were denying the office visit so that is correct.

    Debra A. Mitchell, MSPH, CPC-H

  8. Default From OB/GYN Pink Sheets
    Coder Pink Sheets: Ob/GynACOG: Append 25 to E/M done same day as diagnostic test
    Coder Pink Sheets: Ob/Gyn » Ob/Gyn: Ob/Gyn Coder's Pink Sheet, February 2009, Vol. 8, No. 2

    Effective Feb 1, 2009
    Published Feb 1, 2009


    When you perform a diagnostic test and a significant and medically necessary evaluation and management service on the same day, make sure to append modifier 25 to the appropriate E/M service code, says the American College of Obstetricians and Gynecologists (ACOG). In its January 2009 Practice Management and Coding Update, ACOG reiterates these instructions, while noting that they fly in the face of CPT guidelines. CPT defines modifier 25 as a "significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service."

    The ACOG update says "although Modifier 25 is not usually required by CPT for an E/M service performed on the same day as a diagnostic procedure or test, ACOG recommends its use when submitting these claims."

    CPT's Evaluation and Management Service Guidelines state that "the actual performance and/or interpretation of diagnostic tests/studies ordered during a patient encounter are not included in the levels of E/M services. Physician performance of diagnostic tests/studies for which specific CPT codes are available may be reported separately, in addition to the appropriate E/M code."

    This has generally been interpreted to mean no modifier is required when a physician orders a diagnostic test during an E/M visit, since diagnostic tests do not have any global period (by contrast, even procedures or services with 0-day global periods include E/M services performed on the day of the procedure), and medical necessity alone should determine whether you can report a separate E/M service.

    ACOG says its decision, originally made in 2004 and reiterated in the January Update, to buck CPT policy came "after evaluating payer policies and reviewing extensive member claim denials for E/M services submitted with ultrasound procedures." Appending modifier 25 "indicates to the payers that a distinct and significant E/M service is being performed in addition to the Ultrasound."

    Warning: Modifier 25 is not a free pass: It's important to remember that neither CPT nor ACOG are saying you can always bill a separate E/M service when the ObGyn performs or orders a diagnostic test, with or without a modifier, says OBGPS Technical Advisor Jan Rasmussen, PCS, CPC, ACS-OB, president, Professional Coding Solutions, Holcombe, Wis. "If the diagnostic test was previously scheduled, there is no significant E/M unless you need time to explain results or if the patient has a separate problem."

    "If the results of the test are abnormal, for instance, the ObGyn might spend a lot of time explaining them to the patient or explaining why additional tests are required; you can support a separate E/M service," Rasmussen says. "But if the test comes back normal and little explanation is required, the E/M provided by the ObGyn is already included in the diagnostic test itself. After all, informing a patient about the result of a test is a standard of care; you would not perform a test and not tell the patient the results."

    For example: Say a patient comes in for an ultrasound which returns normal and the ObGyn sees the patient to inform the patient of the normal results and there is no additional plan of care or testing needed. You shouldn't append 25 because there is no separate or significant E/M service. On the other hand, if the test returns abnormal and the ObGyn has to counsel the patient, you can bill the separate E/M service with modifier 25 appended.

    Rasmussen notes the confusion about modifier 25 and diagnostic tests came about because Medicare perceived physicians were automatically billing established patient visit code 99212 whenever the patient showed up for a diagnostic test. Medicare reacted by introducing a new policy, since rescinded, that bundled diagnostic tests with E/M services. Under those guidelines, even if the E/M service was medically necessary, you had to append modifier 25 to override the edit. "Although Medicare rescinded the policy a few months after announcing it, many private payers also began to require modifier 25 and never followed Medicare's decision to abandon the policy," Rasmussen says. "To avoid rejections, ACOG is recommending appending the 25."

    However, you shouldn't simply append modifier 25 to get paid for a separate E/M anytime the ObGyn performs or orders a diagnostic test. "The E/M service must meet the criteria for modifier 25, which means it has to be significant and separately identifiable," Rasmussen says.
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