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kaiser and modifier 25??

  1. Default kaiser and modifier 25??
    Medical Coding Books
    kaiser is now asking us at family practice to use modifier 25 for E/M level if there are other procedure also done. Such as immun, inject. even if its nurse only and marked level 1 (99211) ?? I'M not sure if this is correct. I just don't want them to make us pay them back the money if this information is not correct. Before kaiser told us not to use modifier 25 now there saying to go ahead and use it. Does anyone know anything about this ??

    thank you all in advance
    MsMaddy

  2. #2
    Default
    Quote Originally Posted by MsMaddy View Post
    kaiser is now asking us at family practice to use modifier 25 for E/M level if there are other procedure also done. Such as immun, inject. even if its nurse only and marked level 1 (99211) ?? I'M not sure if this is correct. I just don't want them to make us pay them back the money if this information is not correct. Before kaiser told us not to use modifier 25 now there saying to go ahead and use it. Does anyone know anything about this ??

    thank you all in advance
    MsMaddy
    Get it in writing - tell them you need "full written disclosure" on the policy - you're legally entitled to it. There's a really good chance that you just spoke with someone who didn't know what they were talking about, even if they sounded like they did. Next time somebody tells you something that doesn't make sense, ask for a supervisor and make them explain it until it's crystal-clear. Don't worry about sounding stupid - 1. It's their job to make sure you understand their policies/claim denials, and 2. Sometimes playing dumb is the only way that you can make them realize that they're not making any sense. Trust me, it works.

  3. #3
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    Yes you should use a 25 modifier on the ov when a procedure even an injection is performed. You cannot bill a 99211 when the visit is for an injection, and this is the reason for the 25 modifier. In order to charge a visit and a procedure (even an injection that is performed by the nurse), the PHYSICIAN must have an encounter that is over above and beyond the reason for the procedure. This was a CMS policy change as of I believe it was 07 but may have been 08, where before you did not use a 25 modifier for ov with injections, but this policy was changed. Kaiser is simply going along with CMS policy. If you are charging a 99211 for the nurse to give an injection of any kind then this is wrong and you will not have the justification to use the 25.

    Debra A. Mitchell, MSPH, CPC-H

  4. #4
    Red face
    I should have been more clear - you should dispute what Kaiser's telling you if you're given a blanket statement to always add a 25 modifier to every E/M code, regardless of what else is billed. (I've heard it more than once from other payers, so it happens...)

    Codes such as 96372, and surgical codes billed with an office visit will make a 25 modifier necessary, but if you're biling immunization administrations (90465 - 90474) with a preventive E/M, you shouldn't need a 25 modifier. Check the guidelines in the CPT pertinent to each section (Green pages) and for each code (by backtracking to the beginning of the code group [where the subsection title is in big green letters], and read everything along the way). You'll be instructed to either append a 25 modifier to a significant, separately identifiable E/M code, or to report the E/M separately with no mention of a modifier. Hope that helps!

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