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Thread: 25 modifier w/ov, new pt.

  1. #21
    Join Date
    Apr 2007
    St. Louis, Missouri


    AAPC: Back to School
    Medicare rules state that you only need a 25 modifier on an e&m code if the procedure being performed on the same day has a 10 day global period. If the procedure does not have a global period then you do not need a modifier at all. With this said, other insurance companies may deny the claim unless you put a 25 modifier on the e&m code regardless if there is a 10 day global period or not. In each case make sure that the documentation is there to support billing both an e&m and procedure on the same day.

    Melissa Blow, CPC

  2. #22

    Default 25 Modifier on new patient o/v

    When a patient is seen for a first visit, they must be evaluated before any procedures are performed. It is up to the provider to document a complete new patient visit and state that a decision was made to perform a procedure in that visit. Much depends on the providers documentation.

  3. #23
    Join Date
    Apr 2007
    Jacksonville, Florida - 90417


    I think the OIG identified numerous instances when the decision to perform a procedure was already made and the patient was presenting to have the procedure performed. The E&M part was simply the pre-op on the patient and as such should not be billed in addition to the procedure unless there was something significant that would constitute additional work beyond the usual pre-op. Most of the time if a procedure is performed AFTER the provider does the work up on the patient, as part of his/her plan of treatment, then it would be appropriate to bill both the visit and the procedure. Of course the 25 modifier would be appended to the procedure (if the procedure was not considered major).

    Best Regards,

    Maryann Palmeter

  4. #24
    Join Date
    Apr 2007

    Default 25 Modifier and New Patient

    Hi, Willingham

    25 Modifier is NOTneeded on New Patients. This is referring to CPT codes 99203 or 99202 the E/M codes with the "0" in them...

    I work Medicaid at a OB/GYN office in Tifton, Ga and when I "POP" the new patient's codes on Medicaid's portal, I don't use the 25 Modifier and it pays.

    Once a upon a time I tried this with the modifier 25 and it denied stating "Confilict with Modifier and Procedure". So, I tried without the modifier and it paid this is how I know for sure.

    So if you work Medicaid don't use 25 Modifier on New Patient codes. And really I have noticed that when I don't use 25 modifier on established patient's codes it doesn't matter one way or the other....

    Hope this helps..

    Freda Callahan, CPC-A

  5. #25


    Quote Originally Posted by Willingham View Post
    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. ????????????????????
    Hey Willingham! Great question. I'm not sure who AIS Inc out of DC is. If you look at their editorial board that published this information, you have Attorneys, a Pharmaceutical person and one PhD. No CPC's, no affiliation with CMS, Medicare, Local Medical Assn's, AHIMA, AAPC, any of the coding greats. According to the guidelines for the modifier -25 Significant, separately identifiable E/M service... It does not differentiate between new and established patients. Modifier 25 is intended for new E/M Office Visits as well as established OV. Following the guidelines as put forth by the AMA is the best advice. Hope that helps! Susan R, CPC

  6. #26
    Join Date
    Apr 2007
    Jacksonville, Florida chapter #90417

    Default Mod 25

    I have read most of the chain regarding modifier 25. A little over a year ago I went to CMS's MedLearn website. It contains lots of useful information within the Web-based Training Modules (and free CEU's!!!). Within the Evaluation and Management presentation the information provided was that modifier 25 IS NOT NECESSARY on new patient E/M codes when a separately identifiable service is provided. According to the presentation, although the modifier is not required, the E/M documentation must still meet the definition of a separately identifiable service in order for you to assign the E/M and the CPT on the same date of service. It also had case examples to help the coder/biller understand when it is appropriate for Mod 25 to be used on the E/M in conjunction with the procedure.

    I checked today and I couldn't find the WBT on E/M Modifiers again. Maybe someone else will be able to locate it.

    Here is the web address:

    Another good one to look at is www.trailblazerhealth.com. They have several WBT's on E/M coding and they are one of the fiscal intermediaries for CMS.

    Hope this helps.
    Last edited by csmith24; 01-16-2008 at 06:44 AM.

  7. #27


    Medicare guidelines never include New Patient visits (99201-99205) in the global fee; therefore, modifier -25 is not required on those E&M codes and Medicare will pay for them separately regardless.


  8. #28


    Here's what I've been taught:

    If you know why the patient is coming in, it is not appropriate to bill for an evaluation and management and procedure on the same day. Unless, the patient wants to be seen for something other than what they're getting the procedure for.

    Anytime a patient says, "oh by the way..." Red flag that a possible seperate service is warranted.

    For new patients: you've never seen them so you have to see and evaluate them - and then bill for whatever procedure you are doing. NOW, some payers will fight this and say it's included in the surgery - or just pay the lesser of the two charges.

    Anytime a procedure is billed in conjunction with an E/M - we've ALWAYS put on the 25 modifier (except for new patients, because you aren't modifying anything) If the payers don't want it - they'll tell you - then fix it on the back end - but it's certainly not going to "hurt you".

    I've come to find out that we may be "billing appropriately for seperately identifiable services" HOWEVER - it varies from payer to payer. They're going to do what they want to do anyway so it all boils down to how they want it. If it were cut and dry across the board, we'd never be in this forum to start with.

  9. #29


    I totally agree with you. I am a coding analyst and I also flag providers that over use the 25 modifier. Now if the patient come in for a URI and a lesion is removed that is different and a 25 modifier should be used but to just use a 25 modifer on an E/M....no.

  10. #30
    Join Date
    Apr 2007
    Las Vegas

    Default modifier 25

    I have used mod 25 on a new pt if they have had a procedure done. One of my colorectal docs will do a hemorrhoidectomy for a new pt if they are in so much pain that they cannot wait until the next visit. Or, she will destroy anal warts on a new pt if they are bad enough. I have always appended the mod 25 b/c she does a complete history/exam, then she uses an anoscope to see how extensive the warts are.

    I hope that this helps.
    Malama pono,

    Sundae Yomes

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