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Mod. 25?

  1. Default Mod. 25?
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    I have an ENT doctor that sees patients all of the time for nosebleeds. He did one the other day with a 30901 RT and a 30903 LT. He also added a 99212 with a 25 mod. I have asked him why he did this because his note clearly states that he did the cauterizations and did not have a separately identifiable service or procedure. He told me that he does this on all new patients because he needs to assess the situation before he performs the cauterization. He told me that if it was an established patient or a medicare patient than he would not have charged the E&M. What is the correct process with this scenerio?

  2. #2
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    As a new patient, the physician had no clue if he/she needed the cauterization or not. An E/M (either consultation or new patient depending on scenerio) would be necessary to establish a dx and then the procedure could be performed. Modifier 25 would be needed in this case.

  3. #3
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    Marion, OH
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    If it was a new patient why did he not use the new patient code (99202...)?

  4. #4
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    Quote Originally Posted by MalissaMejia View Post
    I have an ENT doctor that sees patients all of the time for nosebleeds. He did one the other day with a 30901 RT and a 30903 LT. He also added a 99212 with a 25 mod. I have asked him why he did this because his note clearly states that he did the cauterizations and did not have a separately identifiable service or procedure. He told me that he does this on all new patients because he needs to assess the situation before he performs the cauterization. He told me that if it was an established patient or a medicare patient than he would not have charged the E&M. What is the correct process with this scenerio?
    Your physician stated "he does this on all new patients"...that's why I said it would make sense to bill an E/M code (either new or consult depending on the scenerio) with modifier -25 because he would need to evaluate the patient before he could treat. He also said he would not have used the modifier -25 if it were "an established patient". I was agreeing to the modifier usage...not the E/M code. I agree if the patient is new, a 99212 would NOT be appropriate. I am sorry I did not clarify that part.

    You are correct to catch these inconsistencies, and it is your responsibility to querry the physician to ensure proper coding. Once set in their ways, it is difficult to "teach" something new, but this is a financial impact to his/her practice and should be taken seriously.

    1. If your physician met the requirements for an E/M (regardless of new or established) in addition to the procedure, appending modifier 25 to the correct code is proper if allowed by carrier. *Make sure he/she is checking the correct identifier (new, established, consult) and the correct level of the E/M.

    2. If the physician only performed the previously planned cauterization on an established patient, then no E/M code should be used (negating the use of modifier 25 as well) and only the procedure code should be used.

  5. #5
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    Why isn't he documenting said evaluation and management services? Best practice would dictate an assessment to include mechanism of injury, evaluation for abuse, hypertension and coagulation disorders.

  6. #6
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    Quote Originally Posted by MalissaMejia View Post
    I have an ENT doctor that sees patients all of the time for nosebleeds. He did one the other day with a 30901 RT and a 30903 LT. He also added a 99212 with a 25 mod. I have asked him why he did this because his note clearly states that he did the cauterizations and did not have a separately identifiable service or procedure. He told me that he does this on all new patients because he needs to assess the situation before he performs the cauterization. He told me that if it was an established patient or a medicare patient than he would not have charged the E&M. What is the correct process with this scenerio?
    If it isn't documented it didn't happen! He must document his evaluation of patient New or Established in order to charge for it.

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