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25 modifier w/ov, new pt.

  1. Default 25 modifier w/ov, new pt
    Medical Coding Books
    Hi Willingham, I saw your response and wanted to let you know that I attended an audio conference here at my job and it was in regards to Modifiers and it was done by Medicare. They did state that modifier 25 should not be submitted on an E&M code for a new patient. All of us in the conference were shocked because we had never heard of this before. If you go to the Palmetto GBA website under Ohio Part B Carriers then under modifier look up you will find information on all modifiers. I copied and pasted from there website about modifier 25:

    This modifier should not be submitted with E/M codes that are explicitly for new patients only: CPT codes 92002, 92004, 99201-99205, 99281-99285, and 99341-99345. These codes are "new patient" codes and are automatically excluded from the global surgery package, meaning that they are reimbursed separately from surgical procedures. No modifier is required in order for these codes to be separately reimbursed.

  2. #62
    Default OV with -25 modifier
    Hi ,

    We recieve payment for the OV (In case of Established pts )Visit with -25 modifier the level of Visit should be more than 99211 .ie 99212 - 99215. I hope it applies similar to the New pts too .. Certain cases the Cerumen impaction would be only reason for the encounter ,then it is not appropriate to bill both the removal of cerumen and OV code .

    In case of Established pts :
    Most of the Family care Physician provides , just an B12 injection or any vaccination and they bill for both the Visit and admin . Medicare denies the same and pays only for the Admin code . Usually the admin code is inclusive in 99211 .

    It is the Coders responsibility to make aware of the Physician office to ensure that , they are aware of this rule .

    As said by others it is appropriate to use -25 to OV when the level of visit is more than the first level , if there is distingiushable service rendered by the provider and the reason of the visit should be clearly understood and there is correct E/M level is choosen .Dont link the primary dx as same for both the OV and the other service rendered , this may also provoke necessity for denial .

    Note : refer the clinical Example section in Appendix C in CPT book for the CPT codes .

    Regards,
    Kamala CPC
    Last edited by kamala; 04-30-2009 at 01:51 AM.

  3. #63
    Smile About 96372 adn 99211
    Dear Kamala,

    Thank you for sending the reply. I unmderstood about modifier 25, but regardomg 99211 with adminitstration of injection either Depo or vaccination or B12 ext; for administration they pay for 96372 adn also for 99211.

    I am working in private billing company who are working on the defaulte claims like above and insurance paid too. I certainly couldnt understand the correct rules and regulations of these insurances, they change for their conveniances.

    Thanks any way

    B Alloju

    In case of Established pts :
    Most of the Family care Physician provides , just an B12 injection or any vaccination and they bill for both the Visit and admin . Medicare denies the same and pays only for the Admin code . Usually the admin code is inclusive in 99211 .

  4. #64
    Location
    Lakeland, FL
    Posts
    27
    Default
    Then let me ask you this...if a new pt comes in and can barely walk do to a fall. The pt's ankle is swollen, black & blue, and is experiencing a lot of pain. How can the provider assess the problem without an x-ray? You would need to add a -25 with the new pt o/v because the x-ray is being done the same day and to be interrupted by the same provider?

  5. #65
    Default Hospital Consults w/heart cath
    When a patient comes in to the hospital with chest pain, our Cardiologist is asked to see the patient and determines the patient needs to have a heart cath on that same day, to me, that is a reason to use the 25. Anybody else deal with this issue?

    Thanks,
    Debbie
    Cardiology
    KCMO

  6. #66
    Location
    ENGLEWOOD/DENVER
    Posts
    2,338
    Default
    Quote Originally Posted by dja214 View Post
    Then let me ask you this...if a new pt comes in and can barely walk do to a fall. The pt's ankle is swollen, black & blue, and is experiencing a lot of pain. How can the provider assess the problem without an x-ray? You would need to add a -25 with the new pt o/v because the x-ray is being done the same day and to be interrupted by the same provider?
    if you are talking about just an OV and an X-ray, no modifiier is needed on the office visit. The x-ray is diagnostic and not consider a procedure per say.
    Mary, CPC, CANPC, COSC

  7. #67
    Default
    Can anybody site where I might find info regarding using the modifier 25 on the E/M when having labs drawn in the physicians office?

  8. #68
    Default
    You should not have to use a modifier on E/M when drawing labs. These are consider diagnostic. Not a procedure to something else done.

  9. #69
    Red face modifier 25
    Thanks, can you find an official site regarding that? My manager/co-worker doesn't agree but I've not use that modifier when also drawing labs even with a Clea based office but for the life of me don't remember where that came from!!!

  10. Default Modifier 25
    Significant, Separately Identifiable Evaluation and Management Service by the Same Physician on the Same Day of the Procedure or Other Service: It may be necessary to indicate that on the day a procedure or service identified by a CPT code was performed, the patient's condition required a significant, separately identifiable E/M service above and beyond the other service provided or beyond the usual preoperative and postoperative care associated with the procedure that was performed. A significant, separately identifiable E/M service is defined or substantiated by documentation that satisfies the relevant criteria for the respective E/M service to be reported (see Evaluation and Management Services Guidelines for instructions on determining level of E/M service). The E/M service may be prompted by the symptom or condition for which the procedure and/or service was provided. As such, different diagnoses are not required for reporting of the E/M services on the same date. This circumstance may be reported by adding modifier 25 to the appropriate level of E/M service. Note: This modifier is not used to report an E/M service that resulted in a decision to perform surgery. See modifier 57. For significant, separately identifiable non-E/M services, see modifier 59. (01/01/2008).

    If the claim meets all the above criteria,then it is valid

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