Results 1 to 10 of 10

Consults and mod 25

  1. #1
    Default Consults and mod 25
    Exam Training Packages
    We are getting denials from a medicaid payor stating the the 25 mod cannot be used on consult codes unless a different Dx is used. I have searched the oh-so-easy to navigate CMS website and came up with bubkus. I see a few threads on here discussing the use of new pt e/m with the 25. But has anyone had any issues with the 25 and consult codes or found anything for documentation? Much appreciated.

  2. #2
    Default
    Medicaid is the key word here. Even when we follow all coding guidelines that are published and appeal with the documentation we have not had luck with Texas Medicaid paying. It would seem that simply follow their own rules, I just wish they would share a copy, then I wouldn't waste my time appealing
    Rachel C. Ashley, CPC-E/M
    Houston, TX

  3. #3
    Default
    Thanks...that is pretty much what I am assuming at this point. It's their own internal rule because I am not having much luck finding anything elsewhere. Of course, my lovely company does not supply us with CPT assistant which would help.

  4. #4
    Location
    Greeley, Colorado
    Posts
    2,045
    Default
    From what I recall, some Medicaid carriers do not recognize modifiers in general...it's been awhile since I worked with Medicaid. Have you tried filing the claims without the modifier?

  5. #5
    Default response to consults and mod 25
    is the consult done on the same day as the originating E/M service?
    are there any procedures done by the consulting provider?
    wondering why you are using -25 on a consult...

    Quote Originally Posted by spirving View Post
    We are getting denials from a medicaid payor stating the the 25 mod cannot be used on consult codes unless a different Dx is used. I have searched the oh-so-easy to navigate CMS website and came up with bubkus. I see a few threads on here discussing the use of new pt e/m with the 25. But has anyone had any issues with the 25 and consult codes or found anything for documentation? Much appreciated.
    Rachele Porter, AS, CPC, CPC-H, CEDC
    no weapons formed against me shall prosper

  6. #6
    Default
    Quote Originally Posted by racheleporter View Post
    is the consult done on the same day as the originating E/M service?
    are there any procedures done by the consulting provider?
    wondering why you are using -25 on a consult...
    There is no other E/M service on the same day, it's procedures that are being performed. My examples are allergy testing 95004 & 94060 bronchodilation.

    I'm actually not doing the coding on these. I'm working the denial/audits and have to find a reason to fight the denials or argue my case with the coding dept that we're billing incorrectly. Thx.

  7. #7
    Default
    I went to www.trailblazerhealth.com and found Medicare's Modifiers Manual. Under the section for modifier -25 it states "the E/M service may be prompted by the symptom or condition for which the procedure and/or service was provided. As such, different diagnoses are not required for reporting of the E/M services on the same date. The circumstance may by reported by adding modifier -25 to the appropriate level of E/M service." Also, the CPT book states the following for billing your 95004 code: "Do not report E/M services for test interpretation and report. If a significat separately identifiable E/M services is performed, the appropriate E/M service code should be reported using modifier 25." I realize you are dealing with a denial from Medicaid; however, based on the above I would still try appealing their denial with this information. They've already denied the E/M...what have you got to loose?

    Zaida, CPC

  8. Default
    Quote Originally Posted by spirving View Post
    There is no other E/M service on the same day, it's procedures that are being performed. My examples are allergy testing 95004 & 94060 bronchodilation.

    I'm actually not doing the coding on these. I'm working the denial/audits and have to find a reason to fight the denials or argue my case with the coding dept that we're billing incorrectly. Thx.
    If there is no E/M service then you should not use modifier -25.

  9. #9
    Default
    Zaida, thank you for your insight. I always get hung up on that statement also in the CPT book. But like you noticed, this is a medicaid. We will definitely try appealing first. I have not seen that link on the trailblazer website. I will check it out. Thanks!

    Ericka, thank you for your response. However, per the CPT book, mod 25 does not always apply to two E/M codes. "it may be necessary to indicate that on the day a procedure or service identified by a CPT code was performed..." I recently attended a seminar on modifiers and the instructor confirmed that. Unfortunately, my question on this matter came up after the seminar. lol

  10. #10
    Default
    well I've coded an ER visit where the ER MD did a procedure....the orthopedist consulted and did a procedure, therefore I used -25 on both like this (ortho's notes didn't qualify for consult code so ED code was used):
    99284-25
    90774
    99283-25
    20610

    Quote Originally Posted by spirving View Post
    We are getting denials from a medicaid payor stating the the 25 mod cannot be used on consult codes unless a different Dx is used. I have searched the oh-so-easy to navigate CMS website and came up with bubkus. I see a few threads on here discussing the use of new pt e/m with the 25. But has anyone had any issues with the 25 and consult codes or found anything for documentation? Much appreciated.
    Rachele Porter, AS, CPC, CPC-H, CEDC
    no weapons formed against me shall prosper

Similar Threads

  1. Mod 51 vs Mod 59 for ASC use
    By Tracy592 in forum Modifiers
    Replies: 3
    Last Post: 07-08-2015, 01:49 PM
  2. mod 62 denied can I use mod 80?
    By fisher.jaimie@gmail.com in forum Modifiers
    Replies: 6
    Last Post: 05-18-2015, 06:27 AM
  3. Consults
    By lalalisa in forum E/M
    Replies: 2
    Last Post: 03-16-2010, 12:11 PM
  4. mod 25 & mod 59 with a 94664 (inhaler)
    By jsa1517 in forum Modifiers
    Replies: 2
    Last Post: 01-29-2010, 03:46 PM
  5. Help With Consults!!!
    By jfahan in forum E/M
    Replies: 3
    Last Post: 06-04-2009, 12:40 PM

Posting Permissions

  • You may not post new threads
  • You may not post replies
  • You may not post attachments
  • You may not edit your posts
  •  
Enjoying Our Forums?

AAPC forums are a benefit of membership. Joining AAPC grants you unlimited access, allowing you to post questions and participate with our community of over 150,000 professionals.

Join Now Continue Reading Without Full Access

Already a Member?

Login

Close Message

In addition to full participation on AAPC forums, as a member you will be able to:

  • Access to the largest healthcare job database in the world.
  • Join over 150,000 members of the healthcare network in the world.
  • Be a part of an industry leading organization that drives the business side of healthcare.
  • Save anywhere from 10%-50% with exclusive member discounts on courses, books, study materials, and conferences.
  • Access to discounts at hundreds of restaurants, travel destinations, retail stores, and service providers. AAPC members also have opportunities to save on heath, life, and liability insurance.
  • Become a member of a local chapter and attend regular meetings.