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Modifier 25

  1. #1
    Loma Linda
    Default Modifier 25
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    I have an MD that is questioning why he can not bill an E&M consult and a procedure. He is part of our procedure team and he is simply called in to do the procedure. He feels he should be able to bill for the consult with a modifier 25 because he has to do his own personal evaluation of the patient before he can do the procedure. I explained that his payment for his evaluation is included in the procedure and the rules of using the modifier 25. He wants proof that the procedure includes his pre-op exam. Any suggestions?
    Last edited by amsmith; 08-26-2010 at 05:30 PM. Reason: grammar

  2. Default
    Are you asking about pre-procedure eval or pre-op surgery eval?

    If he was called in for a consult and based on that consult he made the decision to do a procedure, then he can code a Consult E&M with mod -25 and the procedure CPT

    But if he was called in to do a procedure he is expected to review the existing documentation and eval the patient's status prior to doing the procedure. He can code the CPT only.

    He can not code an E&M with the procedure unless the patient's status has changed (since the other provider's evaluation and decision for procedure) and it is medically necessary to re-evaluate the patient before proceeding with the procedure.

    Example: pt eval'd and decision for heart cath made that morning. Your Doc is called in to do the cath that afternoon. He gets the cath CPT only unless the patient says "hey I have been having pretty bad chest pain for the last hour" and it is medically necessary to re-evaluate the pt's condition before preceeding with the cath
    Last edited by sbicknell; 08-30-2010 at 08:26 PM.

  3. #3
    Loma Linda
    Default Pre-Procedure Eval
    Thank you!!! Do you know where I can get documentation to back that up? I have been trying to explain that to him... but he wants proof.

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