Results 1 to 5 of 5

Sherin

  1. #1
    Cool Sherin
    Medical Coding Books
    HELP - I need clarification on modifier 25. Here is a scenario: we are seeing an established patient for a new diagnosis of shoulder pain and at that visit it is decided to do a joint injection. How do I justify an E&M with a 25 modifier along with the joint injection if I only have the one diagnosis? In the past I have received denials from the insurance stating it is a bundled service and they pay on the lesser of the two billed which ends up being the office visit and I have to write off the procedure. Please give me web sites to confirm.
    Thanks for any feedback
    Sheri

  2. #2
    Location
    Columbia, MO
    Posts
    12,531
    Default
    There is absolutely no need to use 2 dx codes just because you have an office visit and a procedure. You should not be writing these off you should appeal them. Payers make payment decisions decisions based on trends. Trending has told them that rarely is there sufficient documentation to support the parameters of the 25 modifier. You need to appeal to prove you have an assessment that is over above and beyond the procedure. Such as does he include assessment of the opposit sholder and look at the neck and decide a joint injection instead of a muscle injection. If the documentation is not there then it should not be billed. If the documentation supports and it is not paid then you need to appeal!

    Debra A. Mitchell, MSPH, CPC-H

  3. #3
    Arrow
    Quote Originally Posted by sherin View Post
    HELP - I need clarification on modifier 25. Here is a scenario: we are seeing an established patient for a new diagnosis of shoulder pain and at that visit it is decided to do a joint injection. How do I justify an E&M with a 25 modifier along with the joint injection if I only have the one diagnosis? In the past I have received denials from the insurance stating it is a bundled service and they pay on the lesser of the two billed which ends up being the office visit and I have to write off the procedure. Please give me web sites to confirm.
    Thanks for any feedback
    Sheri
    You dont have to have a different diagnosis - CPT guidelines state that as long as the physician documents a significant/separately identifiable evaluation and management service, above the usual pre-service and post-service work usually associated with the procedure, you can report the E/M in addition to the procedure. The condition prompting the procedure can be the same one that is being evaluated and managed, so different diagnoses aren't required. As long as this wasn't a previously scheduled injection, and the provider documented all of the necessary elements to show that he gathered the relevant history of the present illness, examined the problematic body area /organ system, and made a medical decision as to how to treat the condition, you can report the E/M with a 25 modifier 25...see this for more info:
    https://questions.cms.hhs.gov/app/an...25-be-used%3F:)

    http://www.aafp.org/fpm/2004/1000/p21.html
    Last edited by btadlock1; 04-15-2011 at 07:56 PM.

  4. #4
    Default
    Thanks, information was great. I will start appealing the denials when I use the -25 modifier on OV/procedure combos.
    Sheri

  5. #5
    Default
    Thank you. I will definitely be looking at these services more closely.
    Sheri

Similar Threads

  1. Sherin
    By sherin in forum EMR/EHR Systems
    Replies: 8
    Last Post: 04-20-2011, 07:18 AM

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.