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25 modifier w/ov, new pt.

  1. Default
    Medical Coding Books
    You can use a mod 25 with a new patient consult visit as long as the dictation in your visit covers you. I think they are just worried about the misuse of that particular modifier. It will be ok, ESP on the pateints first visit.

  2. Default Professional Coder
    Per NHIC's Modifier Billing Guide dated 10/2008; the 25 modifier should NOT be submitted with E/M codes that are explicitly for new patients only (92002, 92004, 99201-99205, 99281-99285, 99321-99323 and 99341-99345)

  3. #53
    Default modifier 25
    In my modifier book "Coding with Modifiers" third edition concerning modifier 25, some carriers do not want a modifier, but:
    CMS guidelines (page 64):
    The CMS recognizes the use of modifier 25 with E/M services within the range of CPT codes 99201-99499, 92002-92014, and Healthcare Common Procedure Coding System (HCPCS) level II codes G0101-G0175.

  4. #54
    Jacksonville, FL River City Chapter
    There is nothing in CPT or in the Medicare claims processing manuals that would indicate Modifier 25 should not be used with new patient services.

    That said, SOME Medicare contractors have stated that Modifier 25 is not necessary when submitting claims involving new patient visits to them, but this is a MEDICARE CONTRACTOR-SPECIFIC claims processing issue. We must recognize that there are variations in how each Medicare contractor processes claims.

    It's possible that one or more of you out there may have YOUR Medicare contractor telling you it is not needed when submitting claims TO THEM, but that doesn't mean that it is a universal rule among all insurers, or even all Medicare contractors.

    Seth Canterbury, CPC, ACS-EM
    Last edited by SCanterbury; 02-18-2009 at 08:10 AM.

  5. Smile
    Hi, I am new to the forum but I would like some clarification on the 25 modifier. I generally do the insurance follow up with the cardiology group I work for but also do coding; recently we have been discussing the use of 25 modifier when billing an ov w/echo exams. I believe it is not necessary because there is no issue of bundling. Can someone please clarify this for me?

    New and Confused

  6. Default -25 modifier
    new visit need no modifier
    succeeding usually needs one if
    appropriated by the documents

  7. #57
    Our new patient visits are being paid with/ without -25. I also read somewhere's that new patient do not require -25.

    Page 24

    Billing Tips:
    No supporting documentation is required with the claim when this modifier is submitted.
    However, the patient's medical records must contain information to support the use of modifier -25 and be available upon request. The following are the exceptions:

    o This modifier should not be submitted with E/M codes that are explicitly for new patients only: 92002, 92004, 99201-99205, 99281-99285, 99321-99323, and 99341- 99345. These services are not considered part of the global surgical policy.

    o Use modifier -25 on initial hospital visit (99221-99223), an initial inpatient
    consultation (99251-99255) and a hospital discharge service (99238 and 99239) ,when billed for the same date as an inpatient dialysis service.

  8. #58

    It would be appropriate to perform an evaluation and use the modifier –25 for consultations on new patients who are to have or need a procedure on the same day of service. It is not necessary, however, to attach modifier-25 for an initial visit.

  9. #59
    Quote Originally Posted by lkozak30 View Post
    Per NHIC's Modifier Billing Guide dated 10/2008; the 25 modifier should NOT be submitted with E/M codes that are explicitly for new patients only (92002, 92004, 99201-99205, 99281-99285, 99321-99323 and 99341-99345)
    I have the same article. I added the link for anyone who wants to read it themselves.

  10. #60
    North Carolina
    I wholeheartedly agree with Seth. Medicare came out with the statment about mod 25 and new patients years ago. My own carrier has statements about this 10+ years ago. Since then, CMS does not include this verbiage in the regs. Chapter 12...nothing. MedLearn bulletins...nothing. You will find some independant Medicare contractors that may submit to this old mentality but CMS as a whole, no. My own carrier, who once heeded to this way of thinking, now denies claims without modifier 25. CMS keeps evolving and so will their regs.
    Last edited by RebeccaWoodward*; 03-12-2009 at 02:52 PM.
    Rebecca CPC, CPMA, CEMC

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