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Preventative Med and -25

  1. #1
    Default Preventative Med and -25
    Medical Coding Books
    Hi All!

    I am confursed as to what is considered within the scope of practice when it relates to Preventative Medicine. If a pt comes in for their annual check up and has a ekg done would this be within the scope of practice or would it require a modifier -25? does the same guidelines for a regular EM apply to Prevenative med? Also, are there any references that you can recommend?

    Thanks in advance for your responses.
    Tracy R. Smith, CPC
    Medicare Audtior

  2. #2
    Default
    Quote Originally Posted by TSmith9672 View Post
    Hi All!

    I am confursed as to what is considered within the scope of practice when it relates to Preventative Medicine. If a pt comes in for their annual check up and has a ekg done would this be within the scope of practice or would it require a modifier -25? does the same guidelines for a regular EM apply to Prevenative med? Also, are there any references that you can recommend?

    Thanks in advance for your responses.
    EKG's don't bundle to E/M visits as far as NCCI edits go, so no 25 mod is necessary in that situation. Also, you'd put it on the E/M code if it needed one - 93000's from the medicine section, so 25 modifiers don't apply to it. Check your state laws for scope of practice concerns. EKG's are probably fine for most MD's.

    No, preventive E/M has its own rules. The nature and extent of the history and exam are completely different, and its based on the age and specific risk factors that apply to the patient (The guidelines are intentionally kind of vague).

    Problem E/M's are based around the assessing and treating a specific presenting problem, so the code is based off of the level of difficulty involved in accomplishing those tasks. If you aren't getting enough info from the CPT guidelines for E/M services, try looking up CMS's 1995 and 1997 documentation guidelines for evaluation and management services. They're much more detailed to help with problem-based E/M code selection, and either set is acceptable to use.

    One last thing - the situation you mentioned - if the ekg was done in response to a specific complaint/problem that was brought up during a preventive visit, and not just as a routine screening, you may have grounds to bill both a preventive and problem E/M (with a 25 mod on the problem E/M). It will depend on the quality and content of the documentation, though, so consult with someone who can see the actual notes if you're unsure. You'll probably only get 50% of the allowed amount for the problem E/M from commercial payers (it's a common policy), but that's still $$$ you don't want to leave on the table, if you don't have to.
    Last edited by btadlock1; 12-12-2010 at 11:12 AM.

  3. #3
    Default
    Thanks Brandi, I truly appreciate your response however are you saying that you would NOT add a -25 to a preventative because it is within the scope of practice in this routine visit and you WOULD add a -25 to an EM because this IS a seperatley identifiable service? Am i understanding you correctly? I do understand that documentation needs to support a preventative AND a problem EM. Thanks again for your clarification!!!
    Tracy R. Smith, CPC
    Medicare Audtior

  4. #4
    Default
    That's precisely what I'm saying - whenever you bill a prev. and sick E/M on the same encounter, the sick E/M gets the 25 mod. (The preventive visit is more extensive, so the sick E/M has to go above and beyond the aspects covered during the prev. visit) It would look lke this:

    99394 (for example - not sure of your patient's age)
    99213/25
    93000


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