coding question: the 25 modifier

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PGY2

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I am hoping some of the private practice guys can help me out here. I am a bit confused about when to use the 25 modifier. If you see a patient in the clinic as a new patient evaluation (99204 for instance) and after spending 30-45 minutes doing the H&P, you decide to do a procedure on them the same day in your clinic. Can you bill the 25 modifier for the E/M code (99204-25) along with the 62311 for the epidural for instance?

Thanks in advance for any input.

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Depends on how the insurance carrier reviewer was feeling that day.

Modifier -25

The services described in policies are subject to the terms, conditions and limitations of the Member's contract or certificate. Unless otherwise stated, policies do not apply to Medicare Advantage enrollees. XYZ reserves the right, in its sole discretion, to modify policies as necessary without prior written notice unless otherwise required by XYZ's administrative procedures. The term XYZ includes XYZa, LLC and all of its subsidiaries as appropriate for these policies as well as XYZb and XYZc. Certain policies may not be applicable to Self-Funded Members and certain insured products. Refer to the Member's plan of benefits or Certificate of Coverage to determine whether coverage is provided or if there are any exclusions or benefit limitations applicable to any of these policies. If there is a difference between any policy and the Member's plan of benefits or Certificate of Coverage, the plan of benefits or Certificate of Coverage will govern. Policy #: ADMINISTRATIVE 116.4 T0 Coverage Statement: Policy is applicable to:

Purpose The purpose of this document is to outline policy on evaluation and management services billed with other procedures/services, and the rules XYZ applies to the use of Modifier -25. Definitions Modifier -25 - (as defined by the American Medical Association Current Procedural Terminology: CPT 2005, Professional Edition) Significant, Separately Identifiable Evaluation and Management Service by the Same Physician on the Same Day of the Procedure or Other Service. The modifier was created for situations when the physician needs 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. The E/M service may be prompted by the symptom or condition for which the other 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. Modifier 25 is used to identify a significant, separately identifiable evaluation and management service performed on the same day as another procedure or service by the same provider. Global Days - The global period is the number of days during which all necessary services normally furnished by a physician (before, during, and after the procedure) are included in the reimbursement for the procedure performed. Refer to policy: Global Surgical Package.
Evaluation and Management Services (E/M) - CPT codes 99201-99499 are considered Evaluation and Management codes. The types of E&M services include examinations, evaluations, treatments, conferences with or concerning patients, preventive pediatric and adult health supervision, and similar medical services, such as the determination of the need and/or location for appropriate care and treatment of a patient (e.g., office and outpatient setting, emergency department, nursing facility, etc.).
Procedure/Service (as defined for this policy) - medical services other than an E&M code that has a global days allowance (of 0, 10, 49 or 90).
Policy XYZ follows the Centers for Medicare and Medicaid (CMS) guidelines in reimbursing both an E/M Service and a Procedure/Service having a global days allowance (of 0, 10, or 90) when performed on the same date of service and involving a significant, separately identifiable E/M service above and beyond the other service provided. In addition, XYZ will reimburse non-OB related office Evaluation and Management (E/M) services in addition to global antepartum care when submitted with a -25 modifier. Exception to the global period and use of Modifier 25:An E/M Service will be paid on the same day as a Procedure/Service when a claim is submitted with the CPT/HCPCS code for the procedure with modifier 25 appended as follows:

  • The patient's condition required a significant, separately identifiable E/M service above and beyond the Procedure/Service provided.
  • E/M Services were provided above and beyond the usual preoperative and postoperative care associated with the Procedure/Service that was performed.
NOTE: E/M Services as well as Procedures/Services of physicians and other health care professionals of the same specialty within the same group with the same federal tax identification number are considered as having been performed by the same physician/provider.
XYZ will monitor modifier usage and frequency for appropriate billing of the modifier. Procedures and Responsibilities The following guidelines also apply
  • The initial E/M consultation or evaluation of the problem by the physician to determine the need for surgery or procedure are excluded from the global period and are always payable with or without modifier 25.
  • Non-OB related office Evaluation and Management (E/M) services in addition to global antepartum care when submitted with a -25 modifier.
  • Separately identifiable E/M services performed by the physician on the same day of service are reimbursable when submitted with a -25 modifier, provided the use of the modifier meets the above requirements. Refer to:
 
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Here's an interesting bit of info. The director at one of the ASCs I go to told me that come next month, there must be a 24 hour wait period between the time the ASC receives the request for the procedure and the actual performance of the procedure.
ie---no same day procedures. The administrator was not able to clearly explain why.
 
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To answer your question: Doing the procedure in the office the same day as the consult (as long as it meets the above requirements in my first reply), should be fine to use the 25 modifier. I don't know the details regarding the "same day" ASC rule.
 
Thanks for the reply. However, it still leaves me a little unsure.

Here is an example: let's say an orthopod refers a patient to you for a lumbar facet/medial branch block. Do you do a consult and then a procedure on the same day? Or do you just charge for the procedure? In real life, what are people doing? 99243-25 + 64475, 77003..... or just the 64475, 77003 with no E/M charge?

Or do you guys see the patient on one day and have them come back another for the procedure? Just seems inefficient to have them come back when you could do it right then and there.

Thanks
 
Thanks for the reply. However, it still leaves me a little unsure.

Here is an example: let's say an orthopod refers a patient to you for a lumbar facet/medial branch block. Do you do a consult and then a procedure on the same day? Or do you just charge for the procedure? In real life, what are people doing? 99243-25 + 64475, 77003..... or just the 64475, 77003 with no E/M charge?

Or do you guys see the patient on one day and have them come back another for the procedure? Just seems inefficient to have them come back when you could do it right then and there.

Thanks



ok, heres the deal as best as i know.

if you do a procedure on the same day, you CAN bill the E and M, however it will not be billed at 100%. So in you case, you do the consult, and you do the procedure, you should bill 99204 (if referred directly for the procedure, provided you meet the requiremnts of level 4 or 3 or whatever you choose. typically 3 or 4 is appropriate, rarely level 5) then you bill the 64475, etc. They will pay you 100% for the procedure, and reduce the payment on the E and M, if done in the office, which is what i think you are saying.


Modifier 25 is if it is a SEPARATE problem from the procedure. Ie, you see them scheduled to have MBB or ESI, but they have a new problem of neck pain, and you evaluate that. Then you bill the 99213, or whatever, append the modifier 25 to get paid for the E and M which is a SPEARATE problem and do the procedure...

In an ASC, i dont know, but i assume its the same.


your best bet is, do not do a procedure on the same day as the initial visit. Number one, if it is a private insurance you should get the pre-auth done first. Number 2, it plays chaos on your schedule, at least it does mine. I block 20 minutes, and if i have a new patient, then i do a proceure, i have to block more time, and not all new patients get procedures, etc. you get my drift.

good luck.

dont use the 25 unless it is a separate problem. Take the hit on the E and M if you want to do it that day, or just bring em back, which is what i recommend.
 
whenever i do e/m and procedure on same day i make sure that the diagnosis code for e/m and procedure are not the same AND i make sure that we touch on some part of their pain that may not be directly related to the procedure.... ie: doing ESI for radicular symptoms, but patient also has axial symptoms, therefore i recommended motrin - blablabla...

i hate doing procedure/consults on the same day... it really messes up efficiency and flow - so if a patient drives 3 hours to see me then i'll be accomodating... otherwise the procedure is on another day.

so i trained all referring specialists (especially orthopods/spine surgeons) that i only take referrals for evaluation and i will decide what/which procedure (if there is some weird procedure they'd like me to consider, then they can call and talk to me about it)... so far, no problemo... at first, they were shocked, but i told them that if they already know what procedure is needed for the patient then they can refer to interventional radiology or the block shop 10 miles down the road... just like i don't refer patients to them for an L5/S1 PLIF.
 
g-damn this billing crap pisses me off to no end. purposely ambiguous so as to have an outlet to not pay. in what business world is this ok?

so, just so i am clear, say i see a patient with knee pain as a PCP consult. i dx knee OA and give a knee injection. i dont mention their back, etc. what i am hearing is that i should NOT use the 25 modifier. i should just bill for the E/M and procedure code. is this correct?

agreed that the same day procedure because kills your efficiency on procedural days, but i havent been able to finagle my referring docs to be able to do this. they are all under the mindset of "whats the big deal, its just a shot, why do they have to come back twice". oy.....
 
g-damn this billing crap pisses me off to no end. purposely ambiguous so as to have an outlet to not pay. in what business world is this ok?

so, just so i am clear, say i see a patient with knee pain as a PCP consult. i dx knee OA and give a knee injection. i dont mention their back, etc. what i am hearing is that i should NOT use the 25 modifier. i should just bill for the E/M and procedure code. is this correct?

agreed that the same day procedure because kills your efficiency on procedural days, but i havent been able to finagle my referring docs to be able to do this. they are all under the mindset of "whats the big deal, its just a shot, why do they have to come back twice". oy.....


if it is a NEW patient, then bill the E/M and the procedure, no Modifier.

If it is a f/u patient and they were seen previously for back pain and are following up for this, and now complain of knee pain, and you do the procedure, its is the joint injection, E/M with 25 modifier.

if they are a follow up, and they come for the knee pain, and you inject their knee, then only procedure, no E/M because the E/M component is tied into the "pre, and post portion of the procedure"

its all bull****
 
this issue has come up at our asc-the 24 hour rule or no same day procedure rule-

this is a medicare issue as far as I have been told and has to do with the patient having 24 hours to review their "patient bill of rights". This is only the case for an ASC and NOT for a hospital or office based procedure.

one answer is to mail/email patients prior to office visit their "bill of rights" but honestly I'm not sure what that is.

while there is some merit to protecting patients this new rule unfortunately just slows patient care along with creating paper work, more bureaucracy etc
 
25 modifiers were also a focus of attention for the Medicare OIG recently.

Unless it is an emergency, bring them back for the procedure. It is the standard of care, and no one will fault you for doing it that way. As for your referral sources, explain to them that it is mandated by Medicare. (That being said, we do E/M and procedures on ALL of our patients, but we have a largely medico-legal practice, and so are at minimal risk)
 
25 modifiers were also a focus of attention for the Medicare OIG recently.

Unless it is an emergency, bring them back for the procedure. It is the standard of care, and no one will fault you for doing it that way. As for your referral sources, explain to them that it is mandated by Medicare. (That being said, we do E/M and procedures on ALL of our patients, but we have a largely medico-legal practice, and so are at minimal risk)


e/m AND procedures for everyone? wow. that is some serious pre-screening process. so, this means you wont even see anyone who you are not going to do a procedure on? im not faulting your practice, just making sure i understand your statement.
 
25 modifiers were also a focus of attention for the Medicare OIG recently.

Unless it is an emergency, bring them back for the procedure. It is the standard of care, and no one will fault you for doing it that way. As for your referral sources, explain to them that it is mandated by Medicare. (That being said, we do E/M and procedures on ALL of our patients, but we have a largely medico-legal practice, and so are at minimal risk)

Comp patient are usually okay to do both too as well as some commercial insurances. If a patient is specifically referred for a procedure, then you can "pre-auth" both the E/M and procedure from the commercial payor (as long as you generate appropriate documentation supporting both levels of service. I

I feel this is ethical as most patients referred for a "selective nerve root injection" often have several other issues, sub-optimal PT, etc. So, I'm almost nerve functioning as a pure needle monkey...
 
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talking about work comp.... none of my work comp (varioius companies) negotiate rates as they will often state that they will pay at the State Fee Schedule... i think that is bogus since a lot of those work comp companies aren't even based in this state

any of you guys have success w/ work comp negotiations, any tactics to recommend?
 
talking about work comp.... none of my work comp (varioius companies) negotiate rates as they will often state that they will pay at the State Fee Schedule... i think that is bogus since a lot of those work comp companies aren't even based in this state

any of you guys have success w/ work comp negotiations, any tactics to recommend?

We negotiate for EMGs, MRIs and for ASC rates. Usually we get 3-5x Medicare. We generally match the market rates for WC, sometimes drop 10%. Still quite profitable.
 
what about for consults or the procedures themselves?
 
Thanks for the reply. However, it still leaves me a little unsure.

Here is an example: let's say an orthopod refers a patient to you for a lumbar facet/medial branch block. Do you do a consult and then a procedure on the same day? Or do you just charge for the procedure? In real life, what are people doing? 99243-25 + 64475, 77003..... or just the 64475, 77003 with no E/M charge?

Or do you guys see the patient on one day and have them come back another for the procedure? Just seems inefficient to have them come back when you could do it right then and there.

Thanks

I would question the 99243 and probably look at 99202-99205 with the 25 modifier with the scenario you outlined, especially if the orthopod asks you for a specific procedure to be done. By the referring doc asking for a specific procedure, he has concluded what he finds to be medically necessary for the patient and at that point is not asking you to render an opinion, just provide the treatment.

When a patient is referred to a pain doc, I highly doubt that any provider would just put the patient on the table and administer the injection without taking a complete history, do an exam and then decide what is medically necessary. Thus, you have met all requirements for billing a visit on the same day that you provide treatment and that is completely within the CPT and AAPC coding guidelines.

Additionally, let's say that same orthopod referred a patient to you with a request to consult with them regarding back and leg pain. You then see the patient, do the workup, order an MRI and then schedule the patient for a follow up pending the results of the MRI. The patient comes back a week later, you review the MRI with them and decide to proceed with an injection. You can then bill for a follow up visit and the injection same day with the 25 modifier for the visit. Then let's say you schedule the patient for a 2nd injection and you see the patient prior to that injection to document response to the previous injection and determine that you will proceed with the 2nd, you would not bill a separate visit because no additional workup, medication review, etc. was necessary with this visit.

Visits are billable on the same day as a procedure and you're right, why inconvenience the patient by making them come back another day?

Hope that helps.
 
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see, i feel this system of doing procedures on the same day of a consult (and by the way, i don't allow the surgeons to tell me what procedures to do ---) is not very efficient from a patient flow point of view...

i'd rather have all my procedures clumped together and bang them out - instead of having to be torn back and forth between procedures and E/M...
but that is just my preference...
 
It really depends on how your schedules are set up. I agree that going back and forth between consults and blocks isn't an efficient way to practice. However, if you do your consults in the morning and blocks in the afternoon, you could still see the patient on the same day and the 25 modifier allows you to get paid for it.
 
I would question the 99243 and probably look at 99202-99205 with the 25 modifier with the scenario you outlined, especially if the orthopod asks you for a specific procedure to be done. By the referring doc asking for a specific procedure, he has concluded what he finds to be medically necessary for the patient and at that point is not asking you to render an opinion, just provide the treatment.

When a patient is referred to a pain doc, I highly doubt that any provider would just put the patient on the table and administer the injection without taking a complete history, do an exam and then decide what is medically necessary. Thus, you have met all requirements for billing a visit on the same day that you provide treatment and that is completely within the CPT and AAPC coding guidelines.

Additionally, let's say that same orthopod referred a patient to you with a request to consult with them regarding back and leg pain. You then see the patient, do the workup, order an MRI and then schedule the patient for a follow up pending the results of the MRI. The patient comes back a week later, you review the MRI with them and decide to proceed with an injection. You can then bill for a follow up visit and the injection same day with the 25 modifier for the visit. Then let's say you schedule the patient for a 2nd injection and you see the patient prior to that injection to document response to the previous injection and determine that you will proceed with the 2nd, you would not bill a separate visit because no additional workup, medication review, etc. was necessary with this visit.

Visits are billable on the same day as a procedure and you're right, why inconvenience the patient by making them come back another day?

Hope that helps.


this sounds contrary to what was previously stated. why would you be allowed to add the 25 modifier if you are working up the same issue? isnt that bundled with the E/M it is the same problem?
 
the mod 25 has to be for a Separate and Identifiable problem - technically

i like the idea of doing consults in am and procedures in afternoon - didn't even think of it that way... i have always been doing procedures in the AM just to get them out of the way... but i may change now
 
In this case, reviewing an MRI that you ordered means you are doing additional workup for the same problem and you can and should be paid for that work.
 
http://www.oig.hhs.gov/oei/reports/oei-07-03-00470.pdf

Not necessarily.... if the care is pre-procedure or post-procedure related it could be argued it is not a separate/identifiable problem... so it could be argued that reviewing an l-spine MRI prior to an ESI is pre-procedure care and thus not separate.

look at the link to see what the OIG has to say about this... there are ways around it though, you just have to list an unrelated problem and address it in one form or another (ie: patient has carpal tunnel, recommended wrist splints...)
 
this sounds contrary to what was previously stated. why would you be allowed to add the 25 modifier if you are working up the same issue? isnt that bundled with the E/M it is the same problem?

that is correct. in this case, NO 25 MODIFIER should be used. You bill the NEW PATIENT 99202-05, and the procedure. The E/M will be cut in half. thats life
 
http://www.oig.hhs.gov/oei/reports/oei-07-03-00470.pdf

Not necessarily.... if the care is pre-procedure or post-procedure related it could be argued it is not a separate/identifiable problem... so it could be argued that reviewing an l-spine MRI prior to an ESI is pre-procedure care and thus not separate.

look at the link to see what the OIG has to say about this... there are ways around it though, you just have to list an unrelated problem and address it in one form or another (ie: patient has carpal tunnel, recommended wrist splints...)

Yes, the OIG has been targeting the use of 25 modifier for many years. Further review of the OIG report shows that 27% of the 35% of overpaid claims were "due to the lack of documentation of either the E/M and/or the procedure". All I can say is that as a certified coder, I would not hesitate to bill a separate E/M for review of the MRI that was ordered and not previously reviewed with the patient as long as it was documented in the patient's record.
 
that is correct. in this case, NO 25 MODIFIER should be used. You bill the NEW PATIENT 99202-05, and the procedure. The E/M will be cut in half. thats life


The 25 modifier should not affect your payments, especially half! I'd send an appeal.
 
painbiller : how do you code for this:

Patient had an MRI done at an outside facility and read by crappy radiologist - you do a read of the MRI and generate a dictated note based on that read.

You then call the patient to discuss those MRI findings.

??? i have been including this as part of patient's e/m from their previous visit or tack it on to the EM of next visit - but are there other/better codes i could be using?
 
http://www.oig.hhs.gov/oei/reports/oei-07-03-00470.pdf

Not necessarily.... if the care is pre-procedure or post-procedure related it could be argued it is not a separate/identifiable problem... so it could be argued that reviewing an l-spine MRI prior to an ESI is pre-procedure care and thus not separate.

look at the link to see what the OIG has to say about this... there are ways around it though, you just have to list an unrelated problem and address it in one form or another (ie: patient has carpal tunnel, recommended wrist splints...)
"It is used to report a significant, separately identifiable evaluation and management service performed by the same physician on the day of a procedure. The physician may need to indicate that on the day a procedure or service that is identified with a [Current Procedural Terminology] code was performed, the patient’s condition required a significant, separately identifiable evaluation and management service above and beyond the usual preoperative and postoperative care associated with the procedure or service that was performed...

For example, documentation for one of the records reviewed indicated that a Medicare beneficiary had returned for a nail debridement procedure after a previous visit. The patient’s condition had been evaluated prior to the day of the procedure. The provider documented some E/M services the day of the procedure, but did not document any E/M services above and beyond the services necessary to perform the debridement on the day of the procedure. Therefore, payment for the separate E/M service should not have been allowed.

Twenty-eight percent of all providers in the sample population used modifier 25 on more than 50 percent of their claims, thus using it unnecessarily. Modifier 25 should only be used with the E/M service portion of a Medicare claim and not on the procedure portion of the claim. Therefore, even if used properly for every encounter a provider has with every beneficiary, modifier 25 should be used on no more than 50 percent of services billed...

CMS did note that the majority of improper payments reported stemmed from instances in which the provider failed to furnish the documentation necessary to determine the medical necessity of the service, rather than from uncertainty about the guidelines for using modifier 25."
It doesn't have to be a separate or unrelated problem - only a significant separately identifiable evaluation. I agree with PainBiller on this point.
 
painbiller : how do you code for this:

Patient had an MRI done at an outside facility and read by crappy radiologist - you do a read of the MRI and generate a dictated note based on that read.

You then call the patient to discuss those MRI findings.

??? i have been including this as part of patient's e/m from their previous visit or tack it on to the EM of next visit - but are there other/better codes i could be using?
Telephone Services–Physician
Telephone evaluation and management service provided by a physician to an established patient, parent, or guardian not originating from a related E/M service provided within the previous 7 days nor leading to an E/M service or procedure within the next 24 hours or soonest available appointment;

  • 99441 5-10 minutes of medical discussion
  • 99442 11-20 minutes of medical discussion
  • 99243 21-30 minutes of medical discussion
Telephone Services–Non-Physician
Telephone assessment and management service provided by a qualified nonphysician health care professional to an established patient, parent, or guardian not originating from a related assessment and management service provided within the previous seven days nor leading to an assessment and management service or procedure within the next 24 hours or soonest available appointment;

  • 98966 5-10 minutes of medical discussion
  • 98967 11-20 minutes of medical discussion
  • 98968 21-30 minutes of medical discussion
Coding Guidelines

  • These codes may be reported only for established patients.
  • The patient or patient’s parent/guardian must initiate the contact. These codes may not be used for calls initiated by a provider.
  • Codes 99441-99443 are used only for services personally performed by a physician.
  • Calls resulting in a face-to-face encounter for the same problem within 24 hours (or soonest available urgent appointment) are not reportable. Instead, consider the call part of the pre-service work for the billable E/M service.
  • If the call relates to and occurs within 7 days of another E/M service performed and reported by the same provider for the same problem, the call is not reportable. This also means that a telephone call related to a previous call within 7 days is not reportable, since these codes are themselves an E/M service.
  • Do not report a call that is related to and takes place within the postoperative period of a procedure performed by the same physician. These calls are considered to be part of the global surgical package.
 
i have tried those codes and not getting them paid - except by medicare and with TONS of documentation... with a lot of delays...

i was wondering if there is a code for MRI interpretation?
 
painbiller : how do you code for this:

Patient had an MRI done at an outside facility and read by crappy radiologist - you do a read of the MRI and generate a dictated note based on that read.

You then call the patient to discuss those MRI findings.

??? i have been including this as part of patient's e/m from their previous visit or tack it on to the EM of next visit - but are there other/better codes i could be using?

I say you would include it in the workup of your initial visit (order/request for additional records). Without the phone call, you would review it with the patient on their subsequent visit and include it in the medical decision making process for that day.
 
i have tried those codes and not getting them paid - except by medicare and with TONS of documentation... with a lot of delays...

i was wondering if there is a code for MRI interpretation?

I have been able to get payment from some commercial carriers on the phone call codes but very few so far. Aetna will pay. The requirement is that the phone call is initiated by the patient and it does not result in a subsequent appointment. An example would be a patient who calls in about possible side effects from meds. You call them back and spend 10 minutes (99441) going over the symptoms and advising on what to do (Benadryl, reduce dosage/frequency, etc.) and then you document the phone call in his/her record. No follow up appointment is initiated from this call. You have to document start and stop times of your call then code according to the time. Document, document, document.

You're getting paid by Medicare??? Wow, they usually only cover "face-to-face" encounters.
 
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