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E/M and procedure same day, mod 25

  1. Default E/M and procedure same day, mod 25
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    Hi everyone,

    My billing department is having some problems and is hoping to get some clarification....

    A patient comes into our specialty clinic with knee pain. The doctor completes an office visit (E/M) then decides to do an injection or aspiration/injection.

    We bill a 9920XXXX for the office visit, appended with modifier 25, and also the CPT range 2060XXXX for the injection, as the pt did not come in specifically to receive an injection, and the doctor has done a complete work up, as well as the injection procedure.

    Some insurance companies are denying this, saying that the pt came in for knee pain, for example, and that the injection procedure is not separately identifiable from the E/M...

    Any advice or comments would be most appreciated!!!!

    Thanx so much!

  2. #2
    I code for Rheumatology and see this senario almost every day. You are coding exactly the way we would and I can't see any reason this should be denied. Any other insights out there?

  3. Default E/M on Same Day as Procedure - Mod 25
    I code for a urology practice. We have patients come in for a new patient visit for hematuria. We have evaluated the patient and decided during this visit to perform a cystoscopy. We code the E/M w/ modifier 25 and the 52000 for the cysto. We haven't had a problem with Medicare/Medicaid/Tricare/BCBS paying for both the procedure and the E/M. We normally try to schedule the procedure at a later date, but we have had situations where the doctor feels the need to perform the procedure on the same day.

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