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New Patient Medicare Modifier -25

  1. #1
    Location
    Kalamazoo, MI
    Posts
    10
    Default New Patient Medicare Modifier -25
    Medical Coding Books
    I have a new patient who came in for shoulder pain. During the visit, it was determined that they would get a joint injection for relief. I billed a 99202-25 along with the joint injection. Medicare is denying this stating "Modifier 25 is Invalid with this CPT" Can this be appealed or is this a Medicare rule. How should this be billed?

    Thank you for any help!
    --Jeni

  2. #2
    Default
    We run into this all the time with Medicare. Bill it like this...

    99202
    20610-59

    I'll see if I can find documentation.
    Walker Bachman, CPC, CPPM

  3. #3
    Location
    Greeley, Colorado
    Posts
    2,045
    Default
    Quote Originally Posted by jeniearle View Post
    I have a new patient who came in for shoulder pain. During the visit, it was determined that they would get a joint injection for relief. I billed a 99202-25 along with the joint injection. Medicare is denying this stating "Modifier 25 is Invalid with this CPT" Can this be appealed or is this a Medicare rule. How should this be billed?

    Thank you for any help!
    --Jeni
    It's possible they made a mistake (), as modifier -25 is appropriate on the E/M. We don't usually have problems with Medicare denying a scenario like this. If we do, it's because Medicare denied incorrectly.
    Lisa Bledsoe, CPC, CPMA

  4. #4
    Default
    MY carrier is Cahaba, and they deny this scenario every single time! When we called to find out why, they told us to bill the procedure with a modifier-59!! Is it correct coding? No. .. Does it get paid? Yes. I can't explain it any more than you can.
    Walker Bachman, CPC, CPPM

  5. #5
    Location
    Greeley, Colorado
    Posts
    2,045
    Wink Gotta Love Medicare
    Don't you just love how each carrier has different rules?
    Lisa Bledsoe, CPC, CPMA

  6. #6
    Default
    Quote Originally Posted by Lisa Curtis View Post
    Don't you just love how each carrier has different rules?
    not really....
    Walker Bachman, CPC, CPPM

  7. #7
    Location
    Kalamazoo, MI
    Posts
    10
    Default
    Thank you so much for your help!

  8. Talking Modifier -25 denials...
    Just a heads-up to you all...

    When you submit a scenario such as the one you cite - 99202-25 and 20610 - which is absolutely correct! ...and you receive a denial, the first line of defense is to resubmit because it is not an appropriate denial. IF your carrier goes as far as instructing you to submit the scenario "incorrectly", get this in writing because the day WILL come when the carrier goes after you for submitting charges inappropriately for the purposes of getting paid.

    Sometimes, I think CPC stands for CERTIFIED PARANOID CODER...insurance companies don't always behave according to Hoyle and we, as coders, must protect ourselves...so, make the insurance companies responsible for ALL misinformation they out out there.

    Joyce

  9. #9
    Default
    Our Northern California carrier, Palmetto GBA, specifically states on their website and in their Spring '09 Workshop Booklet that they do not want a modifier 25 on a New patient E/M code (this was news to me!).

    "This modifier should not be submitted with E/M codes that are explicitly for new patients only: CPT codes 92002, 92004, 99201 through 99205, 99281 through 99285, and 99341 through 99345. These codes are 'new patient' codes and are automatically excluded from the global surgery package, meaning that they are reimbursed separately from surgical procedures. No modifier is required in order for these codes to be separately reimbursed."

    Sounds like your carrier does the same.
    K-jag

  10. #10
    Default
    Yes, that is nearly the identical wording we got from our carrier!
    Walker Bachman, CPC, CPPM

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