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office than procedure

  1. Default office than procedure
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    Patient was seen in our office than sent to Surgical Center to have procedure (facet block) we billed the office visit first with should we have added 25 modifier to office vist and billed both at the same time?

  2. #2
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    Quote Originally Posted by imonii View Post
    Patient was seen in our office than sent to Surgical Center to have procedure (facet block) we billed the office visit first with should we have added 25 modifier to office vist and billed both at the same time?
    If your doctor didn't perform the procedure, you don't bill for it, or add a modifier to you E/M. If he did do the procedure, then yes, you need the 25 modifier. Hope that helps!

  3. #3
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    In the case your describing if you are billing in an office setting place of service 11, then the patient arrives at a facility with pos 24 or 22, you would bill it separately such as
    724.4 99202-25 POS 11 --for when the patient was in the office
    and then a separate claim/1500
    724.4 62311 77003 with POS 24 or 22 for when the patient was in the facility

    Below is from the NCCI Policy manual to see if the visit meets the criteria for the 25 modifier

    https://www.cms.gov/nationalcorrectcodinited/


    If a procedure has a global period of 000 or 010 days, it is defined as a minor surgical procedure. The decision to perform a minor surgical procedure is included in the payment for the minor surgical procedure and should not be reported separately as an
    E&M service. However, a significant and separately identifiable E&M service unrelated to the decision to perform the minor surgical procedure is separately reportable with modifier 25.
    The E&M service and minor surgical procedure do not require different diagnoses. If a minor surgical procedure is performed on a new patient, the same rules for reporting E&M services apply. The fact that the patient is “new” to the provider is not sufficient alone to justify reporting an E&M service on the same date of service as a minor surgical procedure. NCCI does contain some edits based on these principles, but the Medicare Carriers (A/B MACs processing practitioner service claims) have separate edits. Neither the NCCI nor Carriers (A/B MACs processing practitioner service claims) have all possible edits based on these principles.
    Example: If a physician determines that a new patient with head trauma requires sutures, confirms the allergy and immunization status, obtains informed consent, and performs the repair, an E&M service is not separately reportable. However, if the physician also performs a medically reasonable and necessary full neurological examination, an E&M service may be separately reportable.
    Version 16.3
    I-12
    Procedures with a global surgery indicator of “XXX” are not covered by these rules. Many of these “XXX” procedures are performed by physicians and have inherent pre-procedure, intra-procedure, and post-procedure work usually performed each time the procedure is completed. This work should never be reported as a separate E&M code. Other “XXX” procedures are not usually performed by a physician and have no physician work relative value units associated with them. A physician should never report a separate E&M code with these procedures for the supervision of others performing the procedure or for the interpretation of the procedure. With most “XXX” procedures, the physician may, however, perform a significant and separately identifiable E&M service on the same date of service which may be reported by appending modifier 25 to the E&M code. This E&M service may be related to the same diagnosis necessitating performance of the “XXX” procedure but cannot include any work inherent in the “XXX” procedure, supervision of others performing the “XXX” procedure, or time for interpreting the result of the “XXX” procedure. Appending modifier 25 to a significant, separately identifiable E&M service when performed on the same date of service as an “XXX” procedure is correct coding.

    b) Modifier 25: The CPT Manual defines modifier 25 as a “significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service”. Modifier 25 may be appended to an evaluation and management (E&M) CPT code to indicate that the E&M service is significant and separately identifiable from other services reported on the same date of service. The E&M service may be related to the same or different diagnosis as the other procedure(s).
    Modifier 25 may be appended to E&M services reported with minor surgical procedures (global period of 000 or 010 days) or procedures not covered by global surgery rules (global indicator of XXX). Since minor surgical procedures and XXX procedures include pre-procedure, intra-procedure, and post-procedure work inherent in the procedure, the provider should not report an E&M service for this work. Furthermore, Medicare Global Surgery rules prevent the reporting of a separate E&M service for the work associated with the decision to perform a minor surgical procedure whether the patient is a new or established patient.

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