Modifier 25 - In Depth Analysis and Best Practice. Webinar Subscription Access Expires December 31.

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1 Modifier 25 - In Depth Analysis and Best Practice Questions Answers Webinar Subscription Access Expires December 31. How long can I access the on demand version? You will find that in the same instructions box you utilized to access this presentation. Subscription access expires December 31, individual purchases will not expire for at least two years. If you are the purchaser, you can find your information through following these steps: 1. Go to & login 2. Go to Purchases/Items 3. Click on Webinars tab 4. Click on Details next to the webinar 5. Find the instructions box in the middle of the page. Click on the link to the item you need (Presentation, MP3 file, Certificate, Quiz) Where can I ask questions after the webinar? The online member forums, where over 100,000 AAPC members have access to help each other with all types of questions. *Forum Posting Instructions* 1.Login to your online account 2.In the middle of the page you will see discussion forums 3.Click on view all top right hand side 4.Select general discussion under medical coding unless you see a topic that suits you more 5.On the top left side of the forum box, you will see a blue button, new thread click on that 6.Type your question and submit 7.Check back in that location for answers as you please

2 Question regarding post op services modifier. If surgeon is using modifier 54 for surgical only and I am billing with modifier 55 for the post op visit only. I see where CMS says I need to use the exact surgery cpt code. So would I not use with modifier 55 for the post op? Correct, you would use surgical code with modifier -55 for post op management, unless the procedure has "0" global days, as in this instance the global package does not apply. The dates of service must reflect the dates care was assumed and relinquised. Post operative managment services should not be submitted until the physician sees the patient for the first time in follow up. For more information and some exceptions, see CMS Internet Only Manual, Pub , Medicare Claims Processing Manual Chapter 12, 40: Surgeons and Global Surgery. Arthrocentsis has a 0 global-day period, so I would normally expect E&M to be inclusive for the same condition. However, ican you use E&M with- 25 for teh visit when the decision is made at that time to perform 20610? Have you ever heard of putting a 24 and 25 on the same claim? Per NCCI, the decision to perform a minor surgical procedure is include in the payment for minor surgical procedure and should not be reported separately as an E/M service. See slide 23. Yes, and E/M may occur on the same day as a minor procedure and within the post operative period of a previous procedure. Medicare allows payment when the documentation supports modifer 25 and modifier 24.

3 If patient has a stress test in the facility, and is discharged the same day, does the discharge day mgt E&M require a - 25? If the same physician performed the E/M service and the stress test, I would recommend using modifier 25 on the E/M (discharge code) Stress test have the global surgery indicator of XXX and are not covered by the global surgical rules. However, with most XXX procedures, the physician may, perform a significant and separately identifiable E&M service on the same date of service which may be reported by appending modifier 25 to the E&M code. This E&M service may be related to the same diagnosis necessitating performance of the XXX procedure but cannot include any work inherent in the XXX procedure, supervision of others performing the XXX procedure, or time for interpreting the result of the XXX procedure. Appending modifier 25 to a significant, separately identifiable E&M service when performed on the same date of service as an XXX procedure is correct coding. I have a question regarding a provider whom is billing an E/M with a scheduled cystoscopy on average 50% of the time. The cystoscopy is diagnostic in nature. The provider is usually doing this when there is a new or modified plan of care for the patient. For mod 24, what if Physician does an injection, 20610, on opposite knee or hip of the one that was operated on yet they have same primary DX, or ? If the patient's condition requires a separate and significant E/M service that is above an beyond what is required for the procedure and the documentation supports the service, this would be appropriate. Modifier 24 is for "an unrelated E/M service by the same physicain during the post operative perdid". Modifer 24 is an E/M modifier and should not be used on the procedure code (cpt 20610).

4 Can a E&M be coded on the day of a MOhs Surgery with a 90 day closure (flap, graft..)? Since G0463 replaces E&M for out-pt clinic visit, is -25 appropriate/required for a separately identifiable service? So when billing a claim you use mod 25 on the E/M when you have a minor surgery procedure( 10day global) and if you have a major surgery ( 90 day global) you would append a 57? Can you use modifier 57 decision for surgery if the primary procedure is mohs (17311) and you do a 90 day global repair procedure? If a patient has been referred to a neurologist for an EMG, would it be appropriate to report an E/M with the EMG if the Dr. documents a complete history and a detailed exam? EM can be coded on day of major surgical procedure, if this is the decsion for surgery, using modifier -57 on the E/M code for decision for surgery. Modifier 25 is only used with minor procedures that have global days of 0 to 10 days. Yes, modifier 25 can be used on the G code as this is considered an E/M visit, I have not seen any documentaiotn from CMS stating otherwise. Correct, but only append modifier 25 if the requirements are met. If only the decision to performed the minor procedure, then this is inluded in the minor procedure. Modifier 57 should be used on the E/M service on the day of or on the day before a procedure with 90 day global surgical period if the E/M service resulted in the decision to perform surgery. This indicates to the payer that the service is not a typical per surgery E/M visit, but that the evaluation itself determined the need for surgery. If it is medically necessary (the patient's condition required a separate and significant E/M service) and and the service is above and beyond the usual pre and post procedure care associated with the procedure. And documentaiton supports the service.

5 Can we code an E&M for a new patient consult where the patient is coming in for a possible Moh's surgery but the physician is evaluating and deciding if another procedure is more appropriate. At the time the new patient is being seen there is no clear decision of what is going to do until he evaluated the lesion? If supported by documentaiton this should be appropriate, as the physician has to evaluate the patient and considered other treatment options. If the patients sole purpose for the visit was Mohs surgery and the examinatin was limited to looking at lesion and deciding to remove it, the E/M service may not be appropriate, as the evaluation before removing is considered part of the pre operative work and not significantly and separately identifiable. For E&M on same-day as a procedure & different conditions, and E&M billed with -SA (NPP in collaboration with MD) or GC (service in part by resident under direction of teaching physician), would you still need a -25? If so, does the -25 go before or after the -GC or -SA? Modifier 25 is a payment altering modifier and should go before GC and SA. Even though there is no official guideline by CMS, conventional practice dictates any modifiers that can affect reimbursement should be listed before modifiers that are information only such as location modifers and statistical modifiers Ok if a patient comes in during the post op period for a second minor surgery but also an e/m meets the requirements for a 25 then can you use a 24 and a 25 modifier Can we bill a 25 modifier on the E&M service if the physician is examining the PT for a disease in both eyes but only injects one eye on that date of service? Yes, both modifers can be used on the same claim f medical necessity and documentation is supported. But also check your payer as some may have specific rules. Yes, as long as all requirements are met for the separate and significant E/M service.

6 I was recently told that if a pt is seen in the Er and has stitches etc, that when they follow up in my clinic I can bill a post-op and get paid. I said I didn't think so since it is same tax id # and usually same phyisician NPI but different location NPI. Wouldn't it still be a with zero charge Physicians who provide follow-up services for minor procedures performed in emergency departments bill the appropriate level of office visit code. However, if the same physician or a physician in the same group removes the stiches this is not separatelty billable, and should be reported with post op visit The ER may however charge a facility E/M visit for removing the stiches. Is it still true that for cerumen removal it has to be more than "washing" in order to use modifer 25 and 69210? Yes, code was revised on January 1, 2014 to clarify that instrumentation is required. This code cannot be reported for ear lavage to remove cerumen. Would you bill the cerumen impaction, irrigation does not Yes, if the criteria is not met for billing CPT 69210, the meet the criteria for billing this code and would be included irrigation would be included in the E/M service. in the E/M service? Patient is schedule for a TPI procedure, provider documents discussed in detail uds results and prescribd medication along with a toradol injecton would this justify usage of modifier 25? It depends on the actual documentation. Often with "scheduled injections" the E/M is not significant & separate because the focus of the visit was related to the performance of the procedure and does not go above and beyond to address further problems.

7 With an ER visit where they use dermabond on a simple laceration can the 120XX code really be used for the repair? No. See the CPT description for these codes. And also the section before the codes under heading Repair (Closure): "Wound closure utilizaing adhesive strips as the sole repair material should be coded using the appropirate E/M codes" For Medicare, if the physician only uses liquid skin adhesive (Dermabond) to close a wound, you should report G0168 If the physician uses sutures or staples in combination with Dermabond for repair, you should report only the appropriate laceration repair code ( ). You should not report G0168 with For 2 hospitalists of different specialties, billing separate name doctor name, but same group practice TIN, 1 does E&M and other does procedure on same patient/dos for different diagnosis, would the -25 still be needed due to the shared TIN? I bill for the physician fee on the ER's and if I notice that the wrong diagnosis code is used, can I change these on my billing? I was told that the codes must match and be in same order as the hospital facility code billing. Tehcnically you do not need a modifier 25 since this is two different physicians, however, I have seen denials on this, because of shared TIN, where the payor has requested modifier 25. Yes, I am not aware of the codes having to match, although in most instances they should. The facilty side billing may include services billed for more than one provider, and does not always match the professional fee billing.

8 It's my understanding that E&M is usually not billable on the same day as chemo admin,. If however, the visit was for management of anemia, pain, etc., would the E&M-25 be allowed? Do you add the modifer 25 to a preventative service in conjuntion with an immunization code and injection code??? Yes, if the patient's condition required a separate and significant E/M service above and beyond the chemo therapy and the documentaiton supports separate E/M service. However, you cannot bille and chemo. See CMS IOM Manual, Pub , Ch.12, F: Chemotherapy Administration (or Nonchemotherapy Injection and Infusion) and Evaluation and Management Services Furnished on the Same Day For services furnished on or after January 1, 2004, do not allow payment for CPT code 99211, with or without modifier 25, if it is billed with a nonchemotherapy drug infusion code or a chemotherapy administration code. Apply this policy to code when it is billed with a diagnostic or therapeutic injection code on or after January 1, Physicians providing a chemotherapy administration service or a nonchemotherapy drug infusion service and evaluation and management services, other than CPT code 99211, on the same day must bill in accordance with using modifier 25. The carriers pay for evaluation and management services provided on the same day as the chemotherapy administration services or a nonchemotherapy injection or infusion service if the evaluation and management service meets the requirements Yes, modifier should be used on the E/M preventative visit when immunization and injection coce.

9 A provider thats works for Consult Pain Mgmt schedules all his f/u visits for pain mgmt with procedures, he does document that patient is coming for pain mgmt, but on the treatment plan does not justify enought information other then heat and message for back pain, would this justify a E/M office visit? Based on the scenario you describe, I would not recommend reporting a separate E/M service for this scenario. However, I don't think this is enough information to establish whether a separate E/M is justified. In the case of pediatrics...patient presents with ear pain or hearring loss, in the exam it is found that patient has impacted cerumen...am I correct in understanding this scenario does not warrant a 25 modifier nor a seperate E & M code? Yes, please see other answers regarding cerumen removal.