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Modifier 25

  1. Question Modifier 25
    Medical Coding Books


    I've been working through many practice exams in preparation for my CPC Exam on Nov. 15th. I'd like to run a practice question by you regarding the use of modifier 25.

    Jane has a family hx of skin melanoma. Her PCP asked for a consult with a dermatologist named Dr. John. Dr. John documented what worked out to be a comprehensive exam, and medical decision making of moderate complexity. He also performed a whole body integumentary photography for monitoring of Jane's skin. He sent a report back to her PCP and told Jane that she should return in one year or before then if anything should change on her skin. What code(s) would you use to report Dr. John's services?

    a. 99244-25, 96904
    b. 99213
    c. 96904
    d. 99204, 96904

    According to the answer key, the answer is "a".
    My question? How can Dr. John code with -25? According to what I have been studying and according to the description of -25 in the CPT book, it must be the same physician doing an unrelated E/M service.

    Thanks for your help.

    JoAnne Stockbower

  2. #2
    The question is how would you code Dr. John's services. He did a consult sent a report back and in addition he performed a whole body integumentary photography. Same physician provided consult and procedure.
    Kiana CPC, CPC-H, BCS-M, BCS-R

  3. #3
    The provider performed a procedure during a consult. When a seperate identiafiable service is provided during an e&M visit, modifier -25 is appropriate.

  4. #4
    Madison Area Chapter in Madison WI
    JoAnne, I think the key here is the definition of Modifier 25. CPT states Modifier 25 indicate the E/M provided was a Significant, Separately Identifiable Evaluation and Management Service by the Same Physician on the Same Day of the Procedure or Other 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

    For example, the provider had to take a history, perform an exam, and make decisions to determining the procedure was needed. This would not be considered part of the procedure.

    Take a look at Appendix A for a full desciption of Modifier 25. Hope this is helpful.
    Happy Coding, Claudia

    Claudia Yoakum-Watson, CPC
    Coding, Compliance, & Reimbursement Solutions
    [email] - website

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