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Thread: 25 modifier w/ov, new pt.

  1. #11
    Join Date
    Apr 2007


    AAPC: Back to School
    I have found that if the new patient comes in and ends up haveing a procedure that you can bill the 25 modifier along with the new patient e/m code

  2. #12

    Default 25 modifier not needed for new patient visits

    It is a general misconception that a 25 modifier is needed for new patient E/M codes when other procedures are being performed on the same day. it is not, however, necessary. This is per many sources but the one that I taking the text below from is: www.medicarenhic.com/cal_prov/articles/modifier25_1006.htm[/url]

    The exception is that if a NEW patient E/M service is explicitly bundled to the procedure by an NCCI edit. In that case, a 25 modifier would be appropriate.

    This is not to say that you will not have inapproptiate denials from payers when a procedure is done on the same day as an E/M visit. I have found that attaching a copy of the modifier guidelines with the claim upon appeal usually works. Not that any of us have time to prepare appeals on claims that are denied in error!!!

    .................................................. .................................................. ..


    New patient E/M. A new patient E/M service, as defined by CPT, is, by its very nature, considered to be a significant, separately identifiable evaluation and management service when documentation guidelines for the E/M service are met. A new patient E/M service does not need to have a modifier -25 appended when a minor procedure/surgery (global period: 000 [same day only] or 010 [10 days]) is performed on the same date. Therefore when billing any global procedures/surgeries, including foot care codes (CMS dropped the NCCI edit), modifier -25 does not need to be appended to the new patient E/M service code.

    If the new patient E/M service is explicitly bundled to the procedure by an NCCI edit, then use modifier -25, when the new patient E/M service has a significant, separately identifiable component(s).


    Hope this helps
    Last edited by boodiful1; 11-19-2007 at 02:52 PM. Reason: forgot a line

  3. #13
    Join Date
    Apr 2007
    Sierra Vista, Az


    It should be a stand alone code, but from a billing and claims processing perspective the majority of payers opt to process the visit as global if the modifier is not attached.

  4. #14

    Wink Modifier 25

    Hi! I have a little expertise with modifier 25. There was a Biller in our office that kept using 57 on a consult and when I looked it up I told her to use 25 because this applies specifically to E/M codes (consults in paticular; new and established pt.). I use it when the doctor says he has done a consult in the hospital (99254) and then decides to do a minor procedure. I ended up calling Medicare to emphasize to the biller why we were not getting paid and they explained that they preferred 25 and 57 is reserved for major surgeries. However, that being said, I have learned through some trial and error that some of the other payers (commercial) don't like 25. They actually prefer 57 <gasp>, Lol. So, be careful with it, okay. I hope this helps.

  5. #15
    Join Date
    Apr 2007
    San Diego



    I wanted to let you know that the difference between modifiers 25 and 57 is based on post-op/global days. They can both be used for all e/m codes - not just consults. You use modifier -25 for "minor" procedures with no-10 day post op days and -57 for "major" procedures requiring +10 days of post op. Hope this helps.
    Sylvia Thompson, CPC
    Billing Supervisor
    San Diego, CA

  6. #16
    Join Date
    Apr 2007


    Well I work as a claim examiner for health insurance company. If another procedure takes place during that same office visit (new or established patient) unrelated to primary reason patient came in then modifier 25 is used for office visit.

  7. #17

    Default 25 modifier w/ov, new patient

    Just a couple of things. The following is out of the CMS manual under B. Services Not Included in the Global Surgical Package:

    "These services may be paid for separately.
    *The initial consultation or evaluation of the problem by the surgeon to determine the need for surgery. Please note that this policy only applies to major surgical procedures. The initial evaluation is always included in the allowance for a minor surgical procedure;" This can be found on page 71.

    On page 75-76:
    4. Evaluation and Management Service Resulting in the Intial Decision to Perform Surgery
    "Moreover, where the decision to perform the minor proecedure is typically done immedicately before the service, it is considered a routine preoperative service and a visit or consultation is not billed in addition to the procedure."

    So, I think that you need to ask yourself of your provider the following question.
    1. At the encounter did the provider do more then what they would normally do if they saw a patient soley for "x" procedure?

    If the answer is yes, then the 25 modifier on the new patient CPT code is valid. If the answer is no then only the procedure code is warranted.

    Good luck with that. You also need to remember the global rules for procedures who have the XXX as their globals as insurance companies will deny the office visit regardless if you have the 25 on them. Here is the guidance on that. This is found in the CCI information on the CMS website.

    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 day 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.

    Ida Landry, CPC
    Traveling Coding Auditor, Geilenkirchen Germany

  8. #18

    Default -25

    Guidance and Outreach
    Guidance to providers regarding the use of modifier 25 is available
    through a variety of sources, such as newsletters, bulletins, and letters
    from contractors and the Centers for Medicare & Medicaid Services
    (CMS). However, the governing source for determining appropriate
    payment is CMS’s “Internet-Only Manual.”9 Chapter 12, section 40.2 of
    the manual states:
    Modifier 25 is used to facilitate billing of evaluation and
    management services on the day of a procedure for which separate
    payment may be made. It is used to report a significant,
    separately identifiable evaluation and management service
    performed by the same physician on the day of a procedure. The
    physician may need to indicate that on the day a procedure or
    service that is identified with a [Current Procedural Terminology]
    code was performed, the patient’s condition required a significant,
    separately identifiable evaluation and management service above
    and beyond the usual preoperative and postoperative care
    associated with the procedure or service that was performed.
    In addition, CMS allows providers to use the Current Procedural
    Terminology (CPT) Manual, published by the American Medical
    Association, as a source of information regarding the use of modifier 25.
    The CPT Manual contains detailed descriptions of the procedure codes


    I guess it doesn't matter if it's a new or established patient as long as a significant, separately identifiable evaluation and management service above
    and beyond the usual preoperative and postoperative care
    associated with the procedure or service that was performed.


    Originally Posted by Willingham
    Can someone share with me if you are aware, whether or not the 25 modifier is acceptable with a new office visit? I read early part of the year that the
    OIG had audited and cited a high error rate when using this modifier with an ov for a new pt. because the new-pt visit is by definition a stand-alone billiable visit. Any thoughts of this???? thanks. Also when coding this ov with a procedure the CCI edits tells you, you need to append the 25 to pass the edit. ????????????????????

  9. #19

    Wink The Key

    The key here is documentation and the CC (chief complaint)

    As an auditor one of the frequent problems I see is lack of appropriate documentation. Let's start with -25. Like any other modifier you have to ensure that the documentation justifies what you are coding.

    In any procedure, minor or major, there is a preprocedure/preoperative examination. For example, if a new pt with complaints of knee pain comes in to see an ortho and has had a history of success with Hyalgan injections and would like to have another series. The physican may do an injection at the visit. Keep in mind that the E/M code may be relatively low. The docs hx would focus on the knee, the review of symptoms may also be low given that the pt has had the series previously so many of the contraindications may be ruled out. The physical examination would be limited to the knee and ensuring that the pt does not have a fever (indication of underlying infection) and the MDM is relatively straightforward given that the pt is not refractory to the tx. The diagnoses and managment options are also low and there is minimal to no risk at all.

    However by definition the pt is new. Since the OV level is really low the physician just needs to ensure there are no contraindications of doing the injections and he would carry out the injection as normal, meaning the only codeable service here would be the injection with the injectable.

    The guidelines for -25 state that the E/M must "be above and beyond the usual preoperative/postoperative care associated with the procedure." It helps to look at the actual procedure note as a stand alone (when no E/M is coded) to get an idea of what your docs do prior to a procedure or query your doc if you have such access.

    I hope this helps

  10. #20
    Join Date
    Apr 2007


    i am in agreeance with being conservative with modifier -25 but i think we are focusing on the first half of the modifier -25 description that states "It is used to report a significant, separately identifiable evaluation and management service performed by the same physician on the day of a procedure" and are not seeing the rest of the statement that says " the patient’s condition required a significant, separately identifiable evaluation and management service above and beyond the usual preoperative and postoperative care associated with the procedure or service that was performed.
    As we all know, procedures carry a little bit of an e/m service in them but if a provider has to thoroughly evaluate a symptom/condition (and documents it) i believe -25 is justified.
    As for whether its a new pt or not, i know new pts shouldnt typically need the -25 but most payers do bundle it into the procedure if the claim presents without -25..........what do you do???
    Dawnelle Beall, CPC, CPMA, CPC-I
    Licensed AAPC PMCC Instructor
    AAPC ICD-10CM Certified Trainer

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