Modifier 25 use with ov

am the Director of Practice management for the Arkansas Medical Society. We are currently involved in a dispute with an insurance carrier over the use of modifier 25. Could someone please address how to bill an office visit new or established patient where procedure code 95004 is billed along with an office visit. Some of using 25 on the ov and being denied and we have carriers that are reviewing all claims with 25 modifiers. CPT® is not clear on the office visit and procedure with no global, such as a injection. The OV is being denied in this incidence as well, with the J code being the only one paid.

Modifier 25 use with ov

Modifier 25 would be appended to the E&M code when there is a significant, separately identifiable E&M service provided above and beyond that which is normally performed as part of the allergy testing (CPT 95004) or other minor (0 or 10 day postoperative global period) procedure/service provided. The documentation would have to be reviewed to determine whether the separate E&M code is appropriate. I would not expect a J code to be billed with 95004 since 95004 includes the antigen practice expense. Other injection codes, such as subq or IM, do not include the J code so the J code may be separately reported. KZA would be happy to help outside the scope of this forum if you have further questions.

Kim Pollock, RN, MBA, CPC
KarenZupko & Associates, Incl.
www.karenzupko.com

How about this one???

This is a more likely scenario where an insurer might deny an E&M with a -25.

An established patient comes in with the complaint of a red bump. On exam they have a big abscess. I perform an I&D. Can I bill a 99213-25 and the CPT for I&D?
Is the E&M justified here since I had to evaluate the bump, examine the patient and then decide on the best treatment?

modifier 25

If it were me, as a coder, I would not bill an E/M separately in this situation. But the Doc, and I am assuming you are, would have to decide if it was significant or not. Here are a few interesting articles.

http://www.aafp.org/fpm/20041000/21unde.html
http://oig.hhs.gov/oei/reports/oei-07-03-00470.pdf
www.ericacodes.com/Mod25_4.2.06.doc

My thinking on the OIG project is what tools did they use as a criteria to determine if it met program guidelines? That tool should be available to everyone.

Modifier 25 and minor surgical procedures

There are two articles in the database: search on modifier 25. One is "Can we perform a E/M service with every procedure" and the other is modifier 25.

This is a area in which CPT and CMS have a slight difference of opinion. Both say that the E/M has to be significant, separately identifiable, etc. CMS, however, says that the pre and post op work for a procedure includes the assessment, decision for surgery, etc. You can read what they say in the articles.

Personally, I think there is some gray in the situation.

If a patient arrives with a condition that is clear (warts) and wants them destroyed, no E/M. If a physician sees a patient for hypertension, the patient mentions a lesion to be assessed, and the physician has the patient return tomorrow for the biopsy, no E/M on that day.

A patient with abnormal uterine bleeding, assessed for the first time by the GYN, then an endometrial biopsy performed: yes, bill both.

When I look at the note, I first look to see if an E/M is documented (you'd be amazed at how often it isn't) and then, was it significant, and medically necessary. Judgement calls, at times.

When speaking to physicians, I say: it's not a question of always or never. If it were, it would be easy.

Separate E/M on day of procedure

Procedures have an inherent 10 / 80 / 10 payment structure - 10% pre-op, 80% intra-op, and 10% post-op. Therefore, any procedure performed has the medical decision making built-in to be paid for the procedure service. As coders, we score what is written in the documentation only, without presuming what could or could not be considered 'appropriate' for what would be medically acceptable. If one reviews documentation, and the scorable elements meet only the medical decision to perform the service, it's the procedure only. If the coder sees in the documentation other scorable elements (ROS, HPI that goes beyond the chief complaint, additional treatment planning), we score that - add in the E/M service and append modifier 25 with diagnoses that support the additional service. It is up to the carrier to decide if they feel separate payment is appropriate. If denied - first review the claim elements. Often times what is coded - is not billed as requested. If it has been submitted properly per the coder's request but still denied, then it is up to a clinician to review the documentation to decide if the medical service provided exceeded what would normally be needed to provide the decision to perform the procedure.