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Modifier 25

  1. #1
    Default Modifier 25
    Medical Coding Books
    Hi All,

    It would be great if anyone an provide examples and scenarios on Modifier 25.

    Thanks in advance for your help.

    Thank you,
    Meera Mohanakrishnan, MSc, CPC, COC, CPC-P, CRC (Risk Adjustment), CCS (AHIMA) ,CPC- I (AAPC Approved Instructor) , Certified ICD 10 Consultant, PAHM |
    Director – Medical Coding Operations and Training

  2. Smile
    Well Woman Exam W/ Problem Visit...


    99213 -25

  3. #3
    Default -25
    A parent takes a 9yr old to the child's physician for an oral poliomyelitis vaccine. The physician's assistant evaluates the child (established pt) & administers the vaccine orally to the child.
    90473 (Immuniz. Admin.,One Vaccine/Toxoid)
    99211-25 (Eval. & Mangmnt.)

  4. #4
    Default -25
    Photochemotherapy is provided for a 34 yr old consultative pt w/ severe dermatosis. The pt receives 8 hrs of treatment. The physician provides a comprehensive history & physical exam w/ moderatley complex medical desicion making.
    99244-25 (Consultation,Office &/or Other Outpt)
    96913 (Photochemotherapy)
    Last edited by christyms; 10-25-2008 at 03:37 PM. Reason: forgot code descriptions to help out

  5. #5
    Smile -25
    Modifier -25 is used to report an E/M service on a day when another service was provided to the pt by the same physician. Or, if a pt came into the office for a visit early in the day & then later in the day needed to return for a separate service, you would report both services using E/M codes & add -25 to the second code.
    Modifier -25 requests payment for both E/M & a minor procedure or two E/M services on same day.

  6. Default
    What type of service was rendered during the second encounter? a procedure or an E/M?
    If it was a 2nd E/M, my suggestion would be to charge one E/M for the whole day but to increase it's level of service (to a level that documentation supports).
    If the patient returned the same day for a procedure or service other that E/M, charge 1 E/M with mod. 25 and than the procedure/service (increase the level of the E/M if the documentation supports it).
    I am not sure that any insurance will pay for 2 visits on the same day, regardless that they were for 2 separate issues......

    CT ENT

  7. Default
    I am sorry, I apparently had cranial flagylation when reading and responding to this........

    Confused in CT.......)

    CT ENT

  8. #8
    Stuart Sailfish Chapter
    Pt presents to the office as a New Patient. CC Sinus Congestion. MD performs a Complete physical exam. addressing areas of the sinus, reviewing Ct scans etc.
    upon physical exam he notices patient has cerumen impaction and debrides the cerumen

    99203 -25 Dx 478.19
    69210 Dx 380.4

    The 99203 was a distinct seperately reported E/M during the same session as a procedure
    Candice Fenildo, CPC, CPMA, CPC-I, CPB, CENTC, CRHC, AAPC Fellow
    Director of Operations
    Ear, Nose and Throat Associates of South Florida, PA

    "Nothing is stronger than the heart of a volunteer"

  9. #9
    Default 25
    Hi All,

    Thank you so much.

    Thank you,
    Meera Mohanakrishnan, MSc, CPC, COC, CPC-P, CRC (Risk Adjustment), CCS (AHIMA) ,CPC- I (AAPC Approved Instructor) , Certified ICD 10 Consultant, PAHM |
    Director – Medical Coding Operations and Training

  10. #10
    Is anyone billing for Wound Care Centers? These are recurring patients usually returning once a week - the doc says he must evaluate the wound before deciding for certain if another debridement is required. Based on this I have been billing the E/M level documented w -25 then the debridement. However today we had a meeting with the reimbursement director over the WCC who advised that we could only bill for both if there was another medical reason for the E/M or if a new wound was present. I thought the -25 could be used as a decision for surgery for minor procedures (0-10 day global). Is that incorrect?
    Mary Beth Gord, CPC

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