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Medicare & mod 25 w/pacemaker

  1. Default Medicare & mod 25 w/pacemaker
    Medical Coding Books
    We have a situation going on....our cardiologist have pacemaker days. When billing the e/m w/the pacemaker check, we normally append modifier 25 to the e/m, because it is a separate and identifyable service. It seems Medicare has been paying for these type of services without the modifier 25. We've been getting payment for services with the modifier and also without the modifier. Has anyone else had anything similar?

    Anyfeed back and or comments would greatly be appreciated.

    Thank you.

  2. Default
    Normally you need a mod -25 on the E&M service to show it was a separate service from the PM eval.

    The only thing I can suggest is that your E&M is coded with a condition (CHF, CP etc) and your routine PM eval is being coded V53.31. The unrelated DX are passing thru both services as payable.

    Just guessing. Curious to what other feedback you get

  3. #3
    In my opinion the code V53.31 is an incorrect dx code. If you look at the icd9 description that code is for reprogramming of the device when it is at its end of life. To me that means this code is acceptable when you are removing and replacing a pacemaker. We bill V45.01 as the dx code for a pacemaker check.

    Also you need to be careful when billing modifier 25. The over usage of this modifier is a high audit alert to carriers especially Medicare. In all of the seminars that I have attended this modifier was extremely over used and questionable. I would be very cautious about doing that all the time. It could represent a red flag to your carriers.

    I would email your medicare representative and see what suggestions they have on billing with the 25.

    Hope this has been helpful
    Jessica Chandler CPC, COC, CPC-P, CPB, CCC
    Charleston, WV

  4. Default
    V45.01 can not be used as a primary DX and V53.31 is not restricted just to PM end-of-life

    If mod -25 is supported by documentation then it is appropriate to code. Most times the physician is evaluating other conditions in addition to the routine PM check.

    If the patient is walking in and out the door for the PM eval only, then and E&M would most likely not be coded.

    It all comes down to if there is supporting documentation for the -25

  5. #5
    I know the V45.01 isn't a primary dx. You have to put the reason for the inserting the pacemaker then the V45.01. This is the way it is stated on the CCC exam. If you answered it without the v45.01 it would be incorrect

    Of course you can use 25 if documentation supports it. However I could doubt that every time a 25 is used it is supported by the appropriate documentation. You also have to watch the cpt guidelines to be sure that you have all the elements of documentation to support it.
    Jessica Chandler CPC, COC, CPC-P, CPB, CCC
    Charleston, WV

  6. Smile
    Thanks for all the feedback & comments!

  7. #7
    We have pacer clinics monthly and use V53.31/V53.32 and then the condition for which the pacer/aicd is used and we use a 25 on the E/M when justified. We do not have any payment problems from WPS or Noridian.

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