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Thread: 25 modifier w/ov, new pt.

  1. #31

    Default 25 modifier w/ new ov

    AAPC: Back to School
    The 25 modifier is appropriate if the E/M is for a significantly different reason from any procedure performed same day, however, in some cases, applying a 57 to the procedure may be more appropriate if the exam for the new ov led the provider to make the decision to do the procedure.

  2. #32
    Join Date
    Apr 2007
    Bettendorf, Iowa


    we bill out new patient E&M with a 25 if it is justified. We've never had an issue with it getting paid but we make sure we have documentation to back it up just in case.

  3. #33

    Default Worried

    Please note that the article you are quoting, and the decision tree that indicates not to use a 25 modifier on a new visit, are NOT written by the OIG, but are independent opinions of AIS health. I quote from the beginning of the decision tree: "Here are decision trees to help. They were developed by Nickie Braxton, former vice president of corporate compliance and legal services at Masonicare in Connecticut. Contact Braxton at nickiebraxton@gmail.com."

  4. #34

    Default SBridges, billing supervisor

    A good rule of thumb for modifier -25 is to ask yourself, when the patient arrived, did the physician know he would be performing this test or procedure? If your scheduler or documented patient's chief complaint does not indicate a specific reason for the visit, your physician took time to evaluate and determine a course of action which should be reimbursed separately from the procedure itself.

  5. #35

    Default Modifier 27 Question

    I have a multidisciplinary clinic that sees patients once a week for the patient's convience. The patient has an E/M visit with the Cardiac EP MD and a separate E/M visit with the Cardiac Heart Failure MD. Do I need to append the modifier 25 to the second E/M visit for that day? The IDX system that we use won't accept the modifier 27. Also, I don't know if it's read as being the same speciality even though it's a different subspeciality.

    Thanks LT

  6. #36
    Join Date
    Apr 2007
    Lubbock, Texas

    Smile Mod 25 w/new pt visit

    I have never seen a denial from using mod 25 BECAUSE it was used with a new pt visit. There have been many times in the 20+ yrs I have coded OB/GYN where a pt is referred to the GYN dr because of specific problems. At the initial visit, the dr decides to do a procedure, the 25 is used to if it is a procedure with a 10day or less global, we use 57 (dec for surg) if it is a longer global period. Example Postmenopausal woman with bleeding problems referred to specialist. At initial exam, due to bleeding dr decides to perform an endometrial bx. New pt OV code with 25 mod and then the Endo Bx code. We occasionally have to appeal with documentation, but most of the time this is paid. Hope this helps.

  7. #37
    Join Date
    Apr 2007
    Las Vegas


    ok, well, how about this:

    My ENT doc does a scope (either 31231 or 31575) on just about every new pt that comes into the office, and he wants both coded out for the same reason. If the patient has cancer, he wants the new pt visit as well as the laryngoscope. I think that he should get either/or. He does not dictate, he either hand writes or draws diagrams as to what his findings are from the scope.

    I would appreciate some input.
    Malama pono,

    Sundae Yomes

  8. #38

    Default E/M with modfier -25 and a procedure


    Why is the patient coming in? Is the doctor working up a problem? (say hoarseness or lump/mass in the neck/throat area or something like that?). Is he trying to figure out what's causing the patient's symptoms? Or if the patient has an established diagnosis, does the physician need to do a laryngoscopy to establish a baseline from which he'll be measure the efficacy of his treatment of the patient over time as part of that initial work up?

    All of those are VERY valid reasons for charging both the E/M *and* the procedure. The E/M is for the work up of the problem. The scope is simply a diagnostic test that he's using to further refine the differential diagnosis or to gather more information needed to know how to treat it.

    Or let me give you another example. Let's say you were working with an orthopedic surgeon and the patient come in with a complaint of pain in their wrist. The doctor takes a history, does an exam -- and decides that they want to do a diagnostic test to gather some more information, but in this case, the diagnostic test is an xray. Would you be saying that the orthopedic doc should bill the E/M code or the xray, but not both? (that's a rhetorical question -- of course you'd say that he should bill both the E/M and the xray!).

    The only difference between an xray and a laryngoscopy in this case is that one is a non-invasive diagnostic test (xray) and the other is an invasive diagnostic test (the laryngoscopy). Invasive diagnostic tests don't fall into the radiology or lab section of the CPT manual. There are lots of them in the medicine section of your CPT manual (90000 series), but there are also a bunch of them in the 10000-69999 series as well. If the decision to do the invasive diagnostic test came about as a result of his work up of the patient's presenting problem, that's a classic case for the use of modifier -25 on the E/M service and billing it along with the procedure.

    Also, there's nothing that says that he has to *dictate* the report from the scope. His documentation DOES need to indicate whether he used the direct technique or an indirect technique (so you know which of the two codes to use). And the results of this test are literally the drawings that you referred to. I'd probably like to see him indicate something about the size of any nodules he saw, and any other pertinent characteristics. I've included some information below off WebMD about this procedure. Essentially, he should probably be including information about his what he's seen beyond the pictures he's drawing -- although if you look at his dictation of the E/M service, I would suspect that you'll see information like this included in his dictation of the entire encounter.

    "Normal: The throat (larynx) does not have swelling, an injury, narrowing (strictures), or foreign bodies. Your vocal cords do not have scar tissue, growths (tumors), or signs of not moving correctly (paralysis).

    Abnormal: Your larynx has inflammation, injury, strictures, tumors, or foreign bodies. Your vocal cords have scar tissue or signs of paralysis."

    Bottom line, depending on the kinds of patients he's seeing in these first visits (whether they are consults or new patients), this is going to be a test that will be medically indicated fairly frequently. Obviously, not all presenting complaints will require it. For example, my son and I both see an ENT. My son was sent to him for evaluation of a suspected broken nose with a possible deviated septum. I went to the same doctor a couple of years latter with unilateral tinnitus. Neither of those presenting complaints are ones that you'd expect that the doctor would need to do a laryngoscopy for. But that same WebMD article listed the following as typical indications for this test:

    *Find the cause of voice problems, such as a breathy voice, hoarse voice, weak voice, or no voice.
    *Find the cause of throat and ear pain.
    *Find the cause for difficulty in swallowing, a feeling of a lump in the throat, or mucus with blood in it.
    *Check injuries to the throat, narrowing of the throat (strictures), or blockages in the airway.

    So if your doctor is seeing alot of patients with those kinds of complaints, yes, it's a perfectly valid test to be billing along with the E/M service, even if the patient doesn't end up having cancer.

    Hope this helps!

    Joan Gilhooly, CPC, CHCC
    Medical Business Resources, LLC

  9. #39

    Default OB GYN coding companion???

    Does anyone know what the "diamond looking" symbol beside the codes 57520 and 58120 in the 2008 coding companion mean?
    Thanks in advance.

  10. #40


    I don't have that companion..but my recollection with those is that it had something to do with CCI edits...maybe mutually exclusive? I may be WAY off..going off memory.

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