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25 modifier w/ov, new pt.

  1. #41
    Location
    International
    Posts
    10
    Default
    Exam Training Packages
    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. ????????????????????
    yes we can append 25 modifier along with a new EM visit but we need to ensure that we append 2 seperate diagnosis for EM and the procedure, so that the usage of 25 modifier becomes very appropriate for the EM

  2. Thumbs up mod 25
    If you look at appendex A in ama cpt book, no where does it say that mod
    25 is only used for established patient cpx, therefore it can be used for new
    or established patient that come in for cpx and have a seperate procedure done. I work at a family practice and I have been using the mod 25 and
    we don't seem to have any problem. Of course you have to used it correctly.

    Msmaddy cpc-a

  3. #43
    Location
    El Paso, Texas
    Posts
    34
    Default Modifier 25
    There is a discussion in the office that I currently work and I need some advice. In the past they have coded a E/M code for an established patient and if this patient requires lab or x-ray they are attaching modifier 25 to this, I feel this is wrong. I dont think that they are using this modifier appropriatly, but I am getting great resistance to stop using the modifier. Are they using this modifier correctly?

  4. Default
    Has anyone ever received a denial for payment on a legitimately performed new patient exam when performed on the same date as a procedure with 0-10 day global period solely because they appended modifier 25 to the E&M service? My guess would be not. If the service was denied, it was probably due to some other reason. As far as I'm concerned, I will continue to add this modifier to my new patient E&M service.

    ~L
    CPC, CGSC, COSC

  5. Default mofifer 25 question
    Here is a scenario in the office i work at. A pcp will refer a pt to us for a cardiac catheterization based on lets says a positive nuclear stress test. A service that we provide is that we will schedule them for what we call a same day cath. We see the pt in consult and our interventionalist review all the data to a complete exam and decide if they are going to procede with a cath. We always have to put a 25 modifier on the consult or we do not get paid. Now a PCP may think that the pt needs a cath but our interventionalist do the work and decide. They have not cathed people on many occasions because they want further testing or whatever. I feel that this is a completely legitimate use of modifier 25 what do you thing?

  6. Default
    I believe you are doing the right thing, Mshelley87. That's the say I would handle it.

    ~L
    CPC, CGSC, COSC

  7. #47
    Location
    St. Cloud, MN
    Posts
    75
    Default Modifier 25 on new patient
    Many payers have edits in their system that if a 25 modifier is not added on the E/M code, new or established, the office visit will be denied. Medicare goes so far to say that even if it is a new patient, you may not automatically add an E/M visit code. The description on the Minnesota local carrier WPS states "The following statements are false: I can always use this modifier for a new patient."
    To me this statement is saying, even if you have a new patient and procedure on the same day, it does not mean you can always just add the modifier 25 for payment. If the new patient E/M visit is appropriate (medically necessary), and documentation clearly shows it, you will be coding correctly billing both. If the documentation and the medical necessity is not there, you should not automatically add a new patient E/M code with the modifier 25.
    I believe in the "old" days before all of the claims edits, it was typically thought of that for new patients and consults that you did not need to add the modifier 25 when a procedure was preformed on the same day. Those days are gone, with all the advanced claim checks.
    Here is the link for the WPS fact sheet on modifier 25:
    http://www.wpsmedicare.com/part_b/ed...odifier_25.pdf
    Last edited by CindyNorling; 06-04-2008 at 05:17 PM.

  8. #48
    Location
    St. Cloud, MN
    Posts
    75
    Default
    Quote Originally Posted by Bobbiep8 View Post
    There is a discussion in the office that I currently work and I need some advice. In the past they have coded a E/M code for an established patient and if this patient requires lab or x-ray they are attaching modifier 25 to this, I feel this is wrong. I dont think that they are using this modifier appropriatly, but I am getting great resistance to stop using the modifier. Are they using this modifier correctly?
    No, you do not need a modifier 25 on an E/M visit when typical office lab and x-rays are performed. You are correct, it would be wrong to add the modifier 25.
    Cindy Norling, CCS-P, CPC-H

  9. Default
    My thought on this is that the "25" modifier refers to a significant separate procedure so that depends on the reason for the initial visit. The patient came in complaining of severe back pain the physician is writing a plan of care for this condition during this evaluation the patient stated that he/she has been having trouble urinatiing, the doc does a urine test and note both findings in his documentation, I think that validates a 25 modifier. I agree it's all once it's in the documentation.


    Gobin
    Alabama
    Last edited by gcoppa; 07-17-2008 at 11:06 PM.

  10. #50
    Location
    Spokane, WA
    Posts
    20
    Default 25 Mod on New Pt Visits
    We recently had 2 CMS reps speak at one of our Chapter meetings and they both said that a 25 modifier is not required on new patient visits.
    ScottShar

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