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E/M, Modifier and one DX

  1. #1
    Default E/M, Modifier and one DX
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    Hi

    Can anyone verify how to code an ov e/m level with a procedure (say 10061).

    I always thought -25 mod gets attached to the e/m level. My new employer says no because in this case the doc assigned only one dx.

    One person told me that they don't bill the e/m level, just the procedure.
    Another person said to bill the e/m without -25 to the e/m level and attach
    -57 to the procedure code.

    If the driving factor is with the number of dx codes, could a sign/sympton dx be coded for the e/m and the docs dx coded to the procedure?

    Thanks!!

  2. #2
    Location
    Columbia, MO
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    WOW! You are getting a lot of conflicting information here!

    First if you have a significant and separately identifiable E&M and a procedure (with a 10 day or less post op global) on the same day you do use a 25 modifer on the E&M.

    You do not need more than 1 dx code on the claim to do this.

    If the patient were scheduled to come in for the procedure and that was all that was offered on that day then you would have a procedure code only.

    If the procedure has more than 10 days in the post op global then you will need a 57 modifier and it is attached to the E&M only not the procedure code.

    You do not code the signs and symptoms with the definitive dx rendered by the physician as that is considered redundant coding.

    Debra A. Mitchell, MSPH, CPC-H

  3. #3
    Default
    Thanks Debra...

    what you said is how I was trained but for some reason the billing office is telling the posters that one of the services (either e/m or the procedure) won't get paid by the insurance company if the same dx is used for both services. I had never heard that this was a problem before in getting claims paid.

    B

  4. #4
    Location
    Columbia, MO
    Posts
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    Should not affect it in any way. If you look at appendix A in the CPT book and look at the paragraph under the 25 modifier, go about 4 lines from the bottom and it says "as such different diagnosis are not required for the use of the 25 modifier" (that may not be word for word I am going from memory here).

    Debra A. Mitchell, MSPH, CPC-H

  5. #5
    Location
    Jacksonville, FL River City Chapter
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    No matter what the CPT book says, there are still several payers, including many state Medicaids, that will not pay if both have the same diagnosis. So while you should get paid for both, some payers may repeatedly deny the E/M if billed with the same diagnosis.

    Some practices have given up arguing with some payers and accept this, or cannot fight it because of language within the contract they have that allows the payer not to strictly abide by CPT coding conventions. If this is not in the payer's contract, you can fight it, but some still choose not to because of the time involved.

    Regardless, every payer does not innapropriately deny an E/M billed with the same dx as a minor sx on the same day, so they shouldn't have a blanket policy that they never bill an E/M on the same day as the procedure. Even if they've had problems with some and don't feel like fighting them, they should bill it to the ones that pay correctly.

    Seth Canterbury, CPC, ACS-EM
    Education Specialist
    University of Florida Jacksonville Physicians, Inc.
    Clinical Data Quality-Education Department
    653 West Eight Street
    Tower I, Suite 606
    Jacksonville, FL 32209
    (904) 244-9643

  6. #6
    Default
    I agree with Debra.

  7. #7
    Location
    Columbia, MO
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    12,561
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    Quote Originally Posted by SCanterbury View Post
    No matter what the CPT book says, there are still several payers, including many state Medicaids, that will not pay if both have the same diagnosis. So while you should get paid for both, some payers may repeatedly deny the E/M if billed with the same diagnosis.

    Some practices have given up arguing with some payers and accept this, or cannot fight it because of language within the contract they have that allows the payer not to strictly abide by CPT coding conventions. If this is not in the payer's contract, you can fight it, but some still choose not to because of the time involved.

    Regardless, every payer does not innapropriately deny an E/M billed with the same dx as a minor sx on the same day, so they shouldn't have a blanket policy that they never bill an E/M on the same day as the procedure. Even if they've had problems with some and don't feel like fighting them, they should bill it to the ones that pay correctly.

    Seth Canterbury, CPC, ACS-EM
    Education Specialist
    University of Florida Jacksonville Physicians, Inc.
    Clinical Data Quality-Education Department
    653 West Eight Street
    Tower I, Suite 606
    Jacksonville, FL 32209
    (904) 244-9643
    If your documentation supports the use of the 25, regardless of whether or not you have one or more than one dx I say you bill it and write a fabulous appeal letter if denied. A major part of HIPPA was the portability of the codes and modifiers. It is always worth the fight when you know you are right!

    Debra A. Mitchell, MSPH, CPC-H

  8. Default
    Debra, I agree with you. It does not matter if the dx code is the same on the procedure and the E/M code. The physician has to explain to the patient all the complication that can happen during and after the procedure. The only time the procedure is bill alone is when the patient is schedule on a different day from the office visit. I work in Florida and Medicaid do recognize Mod 25. Medicaid will and always march to the beat of there own drum. Another thing if the E/M code is a lower level code thats is when the insurance does not consider to pay it. That is just like you billing a administration fee for Chemo and billing an E/M code. The administration fee is paid more than what the o/v. Suggestion do not listen to those billers in your office. Not everyone know what they are doing with medical bill. If this forum does not help you call the insurance company someone there will more likely help you understand why they are not paying on that code.

  9. #9
    Location
    Columbia, MO
    Posts
    12,561
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    Just FYI, I am not sure if you randomly selected the example of chemo, or if that is a situation you deal with but,.. you may not bill a visit level on the same day the patient is to receive chemo, they have sited several reasons for this but primarily just like with the PT draws you have the patient scheduled to come into the office for that purpose. Also remember all payers "recognize" all modifiers. It just may not be posiible for them to adjudicate the modifier via electronic submission. I have filed claims in Florida and have been able to have Medicaid accept the use of the 25 modifier, not without a fight but I did get it done.
    It must be recognized that all procedures containt the physician supervision/explanation of the procedure as a natural and inherent part of the procedure code. That is why you must have an assessment that is over above and beyound what is necessary (significant). The example I give is the popular skin lesion, if the only assessment is for the lesion itself then I have no E&M only the excision, if however the physician goes on to describe a full body survey, then I have a significant assessment but still only one dx.

    Debra A. Mitchell, MSPH, CPC-H

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