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E/M, procedure same day, mod 25

  1. Default E/M, procedure same day, mod 25
    Medical Coding Books
    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
    Columbia, MO
    You will need to appeal with great documentation to show that the criteria for the 25 modifer has been met. Many payers have discovered on post audit/review that the documentation did not support the use of the 25 modifier so they sometimes either routinely or randomly deny these so that you will need to appeal the denial.

    Debra A. Mitchell, MSPH, CPC-H

  3. Default
    Good Morning,

    You will need to include all documentation with the claim in order to have the appeal reviewed. Please check with the specific carrier regarding their specific policy regarding E/M visits the same day as a surgical procedure. Due to the fact that the visit falls on the same day, you may have an argument if the patient was a new patient.

    Also, if the physician determines that there are multiple injections that are necessary and a return to the office at another day or time, please be aware that you cannot bill for an office visit on that particular day since it was part of the original workup. The only time you would be able to claim the office visit on that day is if there is a new chief complaint and the physician is required to perform a new "seperate' workup


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