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Modier 25 and diagnostic test on same day

  1. Default Modier 25 and diagnostic test on same day
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    I am new at coding for a cardiologist and he does diagnostic testing like EKGs, ECHO, TEEs, Holter monitors and Stress testing daily. Is a modifier 25 required on the E/M code for these tests since they are done on the same day? Some people say yes and others say it is not required.

  2. #2
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    Guide to use:
    “Modifier 25 is a Significant, Separately Identifiable Evaluation and Management Service by the Same Physician on the Same Day of the Procedure or Other Service.” It may be necessary to indicate that on the day a procedure or service identified by a CPT code was performed, the patient's condition required a significant, separately identifiable E/M service above and beyond the other service provided or beyond the usual preoperative and postoperative care associated with the procedure that was performed. A significant, separately identifiable E/M service is defined or substantiated by documentation that satisfies the relevant criteria for the E/M service to be reported. 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. This circumstance may be reported by adding modifier 25 to the appropriate level of E/M service. Note: This modifier is not used to report an E/M service that resulted in a decision to perform surgery. Consider the use of modifier 57. For significant, separately identifiable non-E/M services, consider the use of modifier 59.

  3. #3
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    In your example given of an EKG in addition to the E/M, I would say you do not need modifier 25 because the test (service) was a necessary part of the exam and MDM...key components of the E/M code. Another example would be an in-office urine dip to test for UTI. This was necessary for the assessment and MDM of the CC, so no modifier is needed.

    To contrast: If a patient presented to the office with pain in the elbow and after a detailed history and physical exam, was diagnosed with left lateral epicondylitis requiring an injection of Aristospan, then you would append the modifier 25 to the E/M code along with the proper injection code because a service was actually performed for the TREATMENT of a diagnosis in addition to the E/M service provided that day.

    My simplified rationale to understanding modifier 25 in short is: If the service (CPT code) was DIAGNOSTIC (required for the physical exam and/or MDM of the CC), then no modifier 25 is needed on the E/M code. If the service (CPT code) was actually TREATING the condition diagnosed, then modifier 25 is needed on the E/M code.

    To the experts out there, am I on the right track or way off?

  4. #4
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    Quote Originally Posted by terribrown View Post
    In your example given of an EKG in addition to the E/M, I would say you do not need modifier 25 because the test (service) was a necessary part of the exam and MDM...key components of the E/M code. Another example would be an in-office urine dip to test for UTI. This was necessary for the assessment and MDM of the CC, so no modifier is needed.

    To contrast: If a patient presented to the office with pain in the elbow and after a detailed history and physical exam, was diagnosed with left lateral epicondylitis requiring an injection of Aristospan, then you would append the modifier 25 to the E/M code along with the proper injection code because a service was actually performed for the TREATMENT of a diagnosis in addition to the E/M service provided that day.

    My simplified rationale to understanding modifier 25 in short is: If the service (CPT code) was DIAGNOSTIC (required for the physical exam and/or MDM of the CC), then no modifier 25 is needed on the E/M code. If the service (CPT code) was actually TREATING the condition diagnosed, then modifier 25 is needed on the E/M code.

    To the experts out there, am I on the right track or way off?


    This post was 2 years ago, no response ever materialized that I can see. Anyone want to weigh in on this? I would love to have the answer to this question

  5. #5
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    Medicare made significant changes to the NCCI Manuel regarding how to use modifier 25. You will need to understanding the global modifiers (00-010, XXX, YYY, ZZZ, MMM) in addition to what minor procedures have a brief E&M service bundled into them

    Some carriers program their computers to require a modifier 25 for additional services with an E&M, regardless if they are diagnostic or surgical.

    CMS NCCI Manual:
    CHAP1-gencorrectcodingpolicies_final10312012.doc
    Revision Date: 1/1/2013
    CHAPTER I
    GENERAL CORRECT CODING POLICIES FOR
    NATIONAL CORRECT CODING INITIATIVE POLICY MANUAL
    FOR MEDICARE SERVICES
    pages I-17 - I-18

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