Particularly with modifier 25, clear, detailed physician documentation is key to demonstrating their thought process and supporting the medical decision making (MDM) involved during the course of the treatment rendered. Modifier 25 indicates that additional reimbursement is needed to account for the extra E/M work. The following examples might help clarify the difference between significant and insignificant services delivered in the context of a preventive medicine visit. ICD-10-CM CPT, Z00.121 99393 (Preventive Medicine 5-11 years), F90.1 ADHD 99214 25 (Moderate level MDM E/M service). Yes, it is not medically necessary to bill for an E/M. The patient also states that home monitoring has shown fasting blood sugars of 120 mg/dL to 180 mg/dL and some random sugars over 300 mg/ dL. What is Modifier, Read More Modifier 27 | Multiple Outpatient Hospital E/M Encounters On The Same DateContinue, Modifier 91 indicates a repeat lab test on the same day for the same patient. It indicates that a different provider performed a procedure or service that another provider previously performed. We and our partners use data for Personalised ads and content, ad and content measurement, audience insights and product development. It indicates that a patient has received more than one E/M service in the same hospital, on the same day, with different providers. Its not known if private payers will offer the same benefit. Take the complexity out of delivering on-demand care with an industry-leading operating system built specifically for you. The surgical code includes the evaluation services necessary before the performance of the procedure, so no E/M code should be billed. Hi, How can this be ok? Check out our May and June installments. I have been searching for weeks and catch come up with a clear and concise answer. Typically, if the E/M service is unrelated to the minor procedure (i.e., for a different concern/complaint), the E/M may be reported separately. Im not sure why you would use modifier 25 in this case. It is identified by reporting the eligible code without modifier 26 or TC. To report a separate and distinct E/M service with a non-E/M service performed on the same date, see modifier 25." Don't use modifiers 59, XE, XS, XP, or XU, and other NCCI PTP-associated modifiers to bypass an NCCI PTP edit unless the proper criteria for use of the modifiers are met. The patient is given a nonsteroidal anti-inflammatory drug prescription. Example of an encounter resulting in the reporting of both a procedure code and E/M code with modifier 25, with one diagnosis: A patient arrives at your office complaining of bright red blood from the rectum. Q. While you dont need separate notes, physically separating the documentation for the E/M service from documentation for any other same-day procedures or services may help. The clinic will append modifier TC to the appropriate chest X-ray code (e.g., 71045-TC, Radiologic examination, chest; single view-technical component) to account for the cost of supplies and staff. ". Other modifiers related to modifier 25 include modifier 24, which indicates that an E/M service was unrelated to a surgical procedure and was performed during the global period of the surgery. In scenarios such asthis, we advise that every provider, coder, and medical billingservice know and understand thecoding directives of CPT and CCI AND know and understand the unique exceptions that payersmake. However, an E/M service . The decision to boost payment rates was in part the result of a review of new information on the costs of administering COVID-19 treatments to sick patients. Cancer. A neck-to-groin exam is performed, including a pelvic exam, and a Pap smear is taken. The problem is moderate and risk is moderate. Join over 20,000 healthcare professionals who receive our monthly newsletter that contains news updates and access to important urgent care industry resources. C2N Diagnostics LLC, a St. Louis-based biotechnology firm that created a blood test designed to help doctors detect Alzheimer's disease, has added to its executive team with roles focused on . Thank you for pointing that out, Tammie. Some of our partners may process your data as a part of their legitimate business interest without asking for consent. When the doctor examines the ears he notices that the middle ear is very inflamed (pus is present) and the child is extremely uncomfortable. Do not append modifier 26 if there is a dedicated code to describe only the professional/physician component of a given service (e.g., 93010 Electrocardiogram, routine ECG with at least 12 leads; interpretation and report only). A 15-month-old girl presents with a fever (103F) and mom states the patient has been tugging at her right ear for 2 days. ", Modifier 90 | Reference (Outside) Laboratory Explained, Modifier 27 | Multiple Outpatient Hospital E/M Encounters On The Same Date, Modifier 91 | Repeat Clinical Diagnostic Laboratory Test Explained, Modifier 77 | Repeat Procedure by Another Physician/Health Care Professional, Modifier 57 | Decision For Surgery Explained. This additional work would be considered part of the preventive service, and the prescription renewal would not be considered significant. Save my name, email, and website in this browser for the next time I comment. Typical pre- and post-work does not qualify under modifier 25. Please note, Internet Explorer is no longer up-to-date and can cause problems in how this website functions While I am not aware of any rule that requires this, I cannot say for sure there isnt a policy requiring billing through different companies. Make sure your providers show their extra cognitive work, as it will serve a critical role when the payer reviews the claim. However, know your payer and its policy with this complicated coding area. All Rights Reserved to AMA. Join over 20,000 healthcare professionals who receive our monthly newsletter. Code 72040 Radiologic examination, spine, cervical; 2 or 3 views includes both a technical component (X-ray machine, necessary supplies, and clinical staff to support its use) and a professional component (physician supervision, interpretation, and report). Modifier 25 is considered valid on Evaluation and Management (E/M) procedure codes only (based on modifier definition). When using modifier 25, it is vital to ensure that the E/M service meets the criteria for a separate service and that the documentation justifies the use of the modifier. To use modifier 25, the medical documentation must justify performing the separate E/M service. This would not be considered significant because the patient is asymptomatic and preventive medicine services include counseling or guidance on issues common to the patients age group. Documentation should include their clinical status or the barriers they face to getting the vaccine outside their home. If a spinal X-ray is performed at the physicians office, either by a physician or a technician employed by the practice, report 72040 without a modifier because the practice provided both components of the service. Tenderness and swelling are found on exam. Modifier 25 Tip Sheet - Novitas Solutions The E/M service must be provided on the same day as the other procedure or E/M service. High Acuity Patients in Urgent Care: Defining and Solving Acuity Degradation, Front Desk Checklist PDF for Better Urgent Care Billing, How to Retain Patients in a New Era of Urgent Care, Tips for Payer Reviews: How to Handle Pre-payment, Post-payment, and Probe, The provider did not schedule the procedure or service, The provider uncovered signs or symptoms that needed to be addressed, The provider addressed more than one diagnosis, The provider performed work above and beyond normal work for a given procedure. Medicare requires that modifier 25 always be appended to the emergency department E&M code (99281-99285) when provided on the same date as a diagnostic medical/surgical and/or therapeutic medical/surgical procedure(s). Program Memorandum - Centers for Medicare & Medicaid Services The status of previously diagnosed stable conditions would be considered part of the preventive medicine service and not separately billable. Retinal Physician - CODING Q&A: Clarity Comes to Modifier 24 The code for the lesion removal would be linked to the appropriate lesion diagnosis code, and an E/M service linked to hypertension and osteoarthritis diagnosis codes should be submitted as well. The revenue codes and UB-04 codes are the IP of the American Hospital Association. If you find anything not as per policy. Manage Settings You can also post your question to our medical coding and billing forum to seek further insight. . Before billing for a separate E/M with modifier 25 its imperative to determine whether a provider performed any additional work above and beyond the work involved in the procedure. How to Use Modifier 25 Correctly - American Academy of Orthopaedic Surgeons 1. The following situations would not be significant enough to warrant billing a separate E/M service: The patient also complains of vaginal dryness, and her prescriptions for oral contraception and chronic allergy medication are renewed. CPT Codes, Descriptors, and other data only are copyright 1999 American Medical Association (or such other date of publication of CPT).