AAPC - Back to school
Results 1 to 7 of 7

Thread: Medicare & mod 25 w/pacemaker

  1. #1

    Default Medicare & mod 25 w/pacemaker

    AAPC: Back to School
    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. #2


    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
    Join Date
    Apr 2007
    Charleston, WV


    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, CPC-H, CPC-P, CCC
    Charleston, WV[/COLOR]

  4. #4


    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
    Join Date
    Apr 2007
    Charleston, WV


    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, CPC-H, CPC-P, CCC
    Charleston, WV[/COLOR]

  6. #6


    Thanks for all the feedback & comments!

  7. #7
    Join Date
    Apr 2007


    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.

Similar Threads

  1. Does cpt 73562 & 73565 applies to this report w/ mod 59 & 26?
    By she803 in forum Interventional Radiology
    Replies: 4
    Last Post: 10-08-2012, 11:44 PM
  2. using mod GA vs GX when billing Medicare
    By nikkiwel79 in forum Modifiers
    Replies: 1
    Last Post: 07-17-2012, 12:18 PM
  3. 51-vs 59 mod. And medicare
    By gherimicheleCPC in forum Billing/Reimbursement
    Replies: 2
    Last Post: 03-19-2010, 08:39 AM
  4. mod 25 & mod 59 with a 94664 (inhaler)
    By jsa1517 in forum Modifiers
    Replies: 2
    Last Post: 01-29-2010, 02:46 PM
  5. 93293 pacemaker billing Medicare
    By Susan Maruska in forum Medicare Regulations
    Replies: 0
    Last Post: 04-16-2009, 01:16 PM

Posting Permissions

  • You may not post new threads
  • You may not post replies
  • You may not post attachments
  • You may not edit your posts

Enjoying Our Forums?

AAPC forums are a benefit of membership. Joining AAPC grants you unlimited access, allowing you to post questions and participate with our community of over 150,000 professionals.

Join Now Continue Reading Without Full Access

Already a Member?


Close Message

In addition to full participation on AAPC forums, as a member you will be able to:

  • Access to the largest healthcare job database in the world.
  • Join over 150,000 members of the healthcare network in the world.
  • Be a part of an industry leading organization that drives the business side of healthcare.
  • Save anywhere from 10%-50% with exclusive member discounts on courses, books, study materials, and conferences.
  • Access to discounts at hundreds of restaurants, travel destinations, retail stores, and service providers. AAPC members also have opportunities to save on heath, life, and liability insurance.
  • Become a member of a local chapter and attend regular meetings.